Citation Nr: 21015686 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 17-22 475A DATE: March 18, 2021 ORDER Service connection for lung disease, to include chronic obstructive pulmonary disease (COPD), is denied. Service connection for sleep apnea is denied. Service connection for basal cell carcinoma is denied. Service connection for chloracne is denied. New and material evidence has not been received, and the appeal to reopen a claim of service connection for a dental disability is denied. An evaluation of 10 percent, but not in excess thereof, for residuals of a laceration and puncture of the lower lip is granted. An initial compensable evaluation for bilateral hearing loss is denied. An initial evaluation in excess of 10 percent for tinnitus is denied. An initial evaluation of 70 percent, but not in excess thereof, for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted. An effective date earlier than October 15, 2010, for an award of service connection for PTSD is denied. A total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. The Veteran’s lung disability is not related to service other than through his use of tobacco. 2. Sleep apnea is not related to exposure to herbicide agents and is not otherwise related to service. 3. Skin cancer is not related to exposure to herbicide agents and is not otherwise related to service. 4. The Veteran does not have a current disability of chloracne or any other acneform disability. 5. Evidence received since a final March 1976 rating decision is essentially cumulative of the evidence previously of record regarding the basis of the prior denial, lack of a current dental disability for VA compensation purposes. 6. The Veteran’s residuals of a laceration and puncture of the lower lip consist of two painful scars but are not productive of unstable scars, pain in more than two scars, visible or palpable tissue loss, gross distortion or asymmetry of features, or characteristics of disfigurement. 7. The Veteran exhibits, at worst, Level I hearing loss in each ear. 8. The Veteran exhibits recurrent bilateral tinnitus. 9. The Veteran’s acquired psychiatric disability is productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but it is not productive of total occupational and social impairment. 10. VA received the Veteran’s claim of service connection for PTSD on October 15, 2010, and his claims file does not contain any communication prior to that date indicating an intent to claim service connection for any mental health disability. 11. The Veteran’s service-connected disabilities have rendered him unemployable or unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for lung disease (COPD), are not met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.300, 3.303 (2020). 2. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 3. The criteria for service connection for basal cell carcinoma are not met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 4. The criteria for service connection for chloracne are not met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 5. Evidence received since a final March 1976 rating decision is not new and material, and reopening of the Veteran’s claim of entitlement to service connection for a dental disability is therefore not warranted. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. §§ 3.156(a), 3.381, 20.1103 (2020). 6. The criteria for an evaluation of 10 percent, but not in excess thereof, for residuals of a laceration and puncture of the lower lip are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2020). 7. The criteria for a compensable evaluation for bilateral hearing loss are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2020). 8. The criteria for an evaluation in excess of 10 percent for tinnitus are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2020). 9. The criteria for an evaluation of 70 percent, but not in excess thereof, for an acquired psychiatric disability, to include PTSD, are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2020). 10. The criteria for an effective date prior to May 12, 2009, for an award of service connection for PTSD are not met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.400 (2020). 11. The criteria for a TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1965 to September 1968. This appeal is before the Board of Veterans’ Appeals (Board) from April 2014 and March 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In March 2020, the Veteran testified during a Board hearing before the undersigned Acting Veterans Law Judge via videoconference. A transcript is included in the claims file. In January 2021, the Veteran’s representative requested a second hearing before the Board. No cause was given, and no reference was made to the hearing that had already occurred. A claimant has the right to one hearing on appeal. 38 C.F.R. § 20.700(a). The appellant had a full and fair hearing on the issues before the Board. As no good cause was shown for the request, such request for a second Board hearing is denied. 38 C.F.R. §§ 20.600(b), 20.700(a). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain diseases with a relationship to herbicide agent exposure, a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following service in the Republic of Vietnam any time during the period from January 9, 1962 to May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). Notwithstanding any other provision of law, for claims filed after June 9, 1998, a veteran’s disability or death shall not be considered service-connected on the basis that it resulted from injury or disease attributable to the veteran’s use of tobacco products during service. 38 U.S.C. § 1103(a); 38 C.F.R. § 3.300(a). This provision does not preclude the establishment of service connection for a disability or death from a disease or injury which is otherwise shown to have been incurred or aggravated in military, naval, or air service or which became manifest to a requisite degree of disability during any applicable presumptive period. 38 U.S.C. § 1103(b); 38 C.F.R. § 3.300(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for lung disease, to include COPD Service treatment records do not reflect any symptoms of or treatment for lung disease, and no such abnormality was noted at the Veteran’s August 1966 separation examination. VA treatment records reflect that an April 2012 sleep study addressing the Veteran’s sleep apnea also showed hypoxemia suggesting underlying lung disease such as COPD. In July 2012 his physician noted his history of smoking and referred him for pulmonary function testing, which in August 2012 showed moderate COPD. In his March 2013 claim, the Veteran reported that he understands that his COPD is the result of 26 years of smoking tobacco. He stated that he smoked because of peer pressure, acceptability, and encouragement that he encountered in service. In a March 2013 statement, the Veteran’s wife stated that his lung disability was the result of smoking tobacco, a habit which he did not do regularly until his time in service. VA treatment records reflect that in July 2014 the Veteran reported increased difficulty breathing. In September 2014 pulmonary function testing was consistent with moderate COPD and asthma. At his March 2020 hearing the Veteran described how he developed his cigarette habit while in service. In October 2020, the Veteran’s representative provided two articles, stating that they noted “the connection between [Agent Orange] exposure and the Veteran’s medical conditions.” It was unclear for which specific conditions the representative intended to be providing information, though one of them dealt with lung disorders specifically. This article, however, addressed burn pits related to service in the Gulf War, and tobacco use. As discussed above, tobacco use is not a legal nexus for service connection under VA law and regulations. The Board finds that the evidence weighs against a finding that the Veteran’s lung disability is related to service other than through use of tobacco. As discussed above, the Veteran’s disability or death may not be considered service-connected on the basis that it resulted from injury or disease attributable to his use of tobacco products during service. 38 U.S.C. § 1103(a); 38 C.F.R. § 3.300(a). There is no evidence that the Veteran’s COPD or asthma arose in service or is otherwise related to service in any way apart from his use of tobacco. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s lung disability is related to service other than through use of tobacco, and service connection is therefore denied. 2. Entitlement to service connection for sleep apnea Service treatment records do not reflect any symptoms of or treatment for sleep apnea, and no such abnormality was noted at the Veteran’s August 1966 separation examination. VA treatment records reflect that in January 2012 he reported snoring and was diagnosed with probable sleep apnea. In February 2012 he reported loud snoring and apnea witnessed by his wife. He was diagnosed with obstructive sleep apnea and referred for a sleep study. His diagnosis was confirmed by an April 2012 sleep study, and in May 2012 he was provided with a continuous positive airway pressure (CPAP) machine. He continued treatment thereafter. Treatment records do not reference service or any service-related etiology. In his March 2013 claim, the Veteran stated that he was not sure if sleep apnea was related to his Agent Orange exposure, but he believed it might be. In a March 2013 statement, the Veteran’s wife stated that she had witnessed his difficulty with breathing during sleep since 1980 or 1981. She stated that he snored and stopped breathing. At his March 2020 hearing, the Veteran stated that he had stopped using his CPAP since he lost weight. He did not think he had sleep apnea anymore. He stated that he believed sleep apnea was related to service because he first started hearing complaints about his snoring about three years after separation from service. He stated that he never snored before service. VA treatment records reflect that in September 2020 after additional sleep studies the Veteran was diagnosed with persistent sleep apnea despite his weight loss. The Board finds that the evidence weighs against a finding that the Veteran’s sleep apnea is related to exposure to herbicide agents or is otherwise related to service. His only argument that sleep apnea is related to service is the fact that he did not have sleep apnea prior to service and his speculation that it was caused by herbicide agents. There is no indication, including the Veteran’s statement, that sleep apnea actually began in service. The Veteran was not diagnosed with sleep apnea until 2012, more than 40 years after separation from service. Moreover, he stated that he was first told about his snoring three years after separation from service. Even if there were corroborating evidence of apneas this early, onset three years after separation is insufficient to establish a relationship to service. As to his belief that his sleep apnea was caused by his exposure to herbicide agents, sleep apnea is not among the disabilities for which VA recognizes a presumptive relationship to herbicide agent exposure, and there is no indication of such a relationship beyond speculation. While he was presumptively exposed to herbicide agents during his service in Vietnam, he has provided no basis for his belief in a relationship between sleep apnea and herbicide exposure, nor is there any medical evidence of such a relationship. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s sleep apnea is related to exposure to herbicide agents or is otherwise related to service. Service connection is therefore denied. 3. Entitlement to service connection for basal cell carcinoma Service treatment records do not reflect any symptoms of or treatment for skin cancer, and no such abnormality was noted at the Veteran’s August 1966 separation examination Private treatment records reflect that in January 2004 the Veteran reported that over the prior six months he noted a growth on his left parietal scalp. He reported a history of skin cancer on the face in 1996, 1998, and 2000. The lesion was surgically excised and on biopsy was diagnosed as basal cell carcinoma. In a December 2010 statement, the Veteran’s sister reported that he has had many skin cancers removed from his body. In a June 2011 statement, the Veteran reported that as a result of his Agent Orange exposure, he noticed little sores not long after separation. He reported that he had two biopsies and two surgeries and was treated for 10-15 pre-cancers, all of which were believed to be basal cell carcinoma. He stated that his dermatologists were always asking if he had exposure to Agent Orange. He stated that every six months they would find another one. Over the years he reports he had 30-50 surgeries and hundreds of pre-cancers removed. In an accompanying statement, his wife reported that he has had issues with skin cancer since they met in 1981. She reported that many of his doctors believed his skin cancer might be related to Agent Orange. In a March 2013 statement, the Veteran’s wife stated that he had skin cancer more often than anyone she had ever known. She stated that there was no history of skin cancer in his family and that they later learned that it was due to his exposure to Agent Orange. VA treatment records reflect that in September 2013 the Veteran was noted to have neoplasms of uncertain etiology on the right chest and right posterior calf. Biopsies in October 2013 showed an epidermal nevus of the right calf and basal cell carcinoma on the right chest. The carcinoma was excised in November 2013. In May 2014 he was noted to have neoplasms on the right lateral cheek and the left upper arm. Biopsies in June 2014 showed basal cell carcinoma in both, with excision in July 2014. In December 2014 he was noted to have a neoplasm on the left temple. In January 2015 a biopsy showed basal cell carcinoma. It was excised in February 2015, when he was also noted to have another neoplasm on the left temple. Biopsy on the second left temple neoplasm in March 2015 showed no malignancy. In September 2015 he was noted to have neoplasms on the right upper back, the right posterior neck, and the left anterior shoulder. Biopsies showed two basal cell carcinomas and a squamous cell carcinoma. They were excised in October 2015. In February 2016 he was diagnosed with dermatitis versus cancer on the right leg and right scalp. Biopsies showed basal cell carcinoma. In August 2016 he was noted to have neoplasms on the right medial calf, posterior left shoulder, and anterior left shoulder. Biopsies showed two basal cell carcinomas and actinic keratosis of the left anterior shoulder. The carcinomas were excised in October 2016. An additional lesion was noted on his back, and in November 2016 a biopsy showed a basal cell carcinoma with a compound melanocytic nevus with mild atypia. In May 2017 he was noted to have a neoplasm on his right shoulder. A June 2017 biopsy showed basal cell carcinoma. In November 2017 he was noted to have neoplasms on his central posterior neck, left posterior neck, right back, and right anterior shoulder. Biopsies showed that all except the shoulder were basal cell carcinomas. In May 2018 two neoplasms were noted on the right chest and left chest. Biopsies showed a squamous cell carcinoma and seborrheic keratosis. In July 2019 he was noted to have neoplasms on the left mid lateral back, the left posterior shoulder, the left sideburn, and the left shoulder. Biopsies showed a squamous cell carcinoma, a basal cell carcinoma, and two actinic keratoses. In January 2020 he was noted to have neoplasms on the left ear, the right forearm, and the right pretibial. Biopsies showed actinic keratosis of the ear and two basal cell carcinomas. In a March 2020 statement associated with his application for a TDIU, the Veteran reported that his basal cell carcinomas were exacerbated by his exposure to Agent Orange, which causes this type of cancer to become more prominent. In October 2020, the Veteran’s representative provided two articles, stating that they noted “the connection between AO exposure and the Veteran’s medical conditions.” It was unclear for which specific conditions the representative intended to be providing information, though one of them dealt with lung disorders only. The other article was the 2018 Update to the study on Veterans and Agent Orange by the National Academies of Sciences, Engineering, and Medicine. The paper concluded that there was inadequate or insufficient evidence to determine whether there is an association between exposure to herbicide agents and basal cell or squamous cell skin cancers. The Veteran’s representative also provided an article which discussed government cover-ups related to Agent Orange but did not provide specific medical or scientific information relevant to the Veteran’s claimed disabilities. The Board finds that the evidence weighs against a finding that the Veteran’s skin cancer is related to exposure to herbicide agents or is otherwise related to service. There is no indication that skin cancer arose in service. The Veteran has not articulated any basis for service connection apart from his belief that his skin cancer was caused by his exposure to herbicide agents. Basal cell or squamous cell carcinomas are not among the disabilities for which VA recognizes a presumptive relationship to herbicide agent exposure, and there is no indication of such a relationship beyond the speculative evidence submitted. While he was presumptively exposed to herbicide agents during his service in Vietnam, he has provided no persuasive basis for his belief in a relationship between skin cancer and herbicide exposure, nor is there any medical evidence of such a relationship. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s skin cancer is related to exposure to herbicide agents or is otherwise related to service. Service connection is therefore denied. 4. Entitlement to service connection for chloracne Service treatment records do not reflect any symptoms of or treatment for chloracne, and no such abnormality was noted at the Veteran’s August 1966 separation examination. VA treatment records reflect that in July 2010 the Veteran reported some lesions and was diagnosed with two actinic keratoses. In January 2012 he reported dry and flaky skin on his arms and legs. He was diagnosed with seborrhea and eczema and instructed to use a dandruff shampoo. In his March 2013 claim, the Veteran reported that he believed he had chloracne for many years as a result of his exposure to Agent Orange. He reported that he had been using medication and lotions for many years with very little relief. In a March 2013 statement, the Veteran’s wife stated that he had had a chloracne-like rash for 33 years. VA treatment records reflect that in September 2013 the Veteran was diagnosed with intradermal nevus on the right lateral upper cheek and solar keratosis on the dorsal right hand. In May 2014 he reported to his dermatologist that he had been told that he had chloracne. He was diagnosed with rosacea and candidiasis. In December 2014 he was diagnosed with seborrheic keratosis. In February 2015 his seborrheic dermatitis was gone. In May 2017 he was diagnosed with actinic keratoses and seborrheic keratoses. In January 2019 he was diagnosed with seborrheic keratosis on the central mid-back, actinic keratosis on the right lower extremity, and a probable lipoma of the central upper back. At his March 2020 hearing, the Veteran stated his belief that chloracne was “probably close” to the skin symptoms he had experienced between his basal cell carcinomas and other skin disabilities. The Board finds that the evidence weighs against a finding that the Veteran has a current disability of chloracne. There is no evidence that he has been diagnosed with chloracne or any other acneform disease. At his March 2020 hearing, the Veteran stated that he believed that his basal cell carcinoma was “probably” close to chloracne, but there is no medical evidence to support this assertion. Even if the Board were to find that his carcinomas, dermatitis, or keratoses were acneform disabilities, chloracne is one of the few disabilities for which VA recognizes a presumptive relationship to herbicide agent exposure only if it has an onset within one year of such exposure. See 38 C.F.R. § 3.307(a)(6)(ii). The evidence does not, however, support a current diagnosis for an acneform disability. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While the Veteran clearly has disorders affecting the skin, and while these are presumed to result in functional impairment of earning capacity, chloracne is a specific disease entity. To qualify as an herbicide presumptive disease, a diagnosis of chloracne is required. As such, the Board finds that the evidence weighs against a finding of a current disability of chloracne, and service connection must therefore be denied. 5. Whether new and material evidence has been received to reopen a claim of service connection for a dental disability Under VA law, compensation is only available for certain types of dental and oral conditions, which are rated under 38 C.F.R. § 4.150, Diagnostic Codes 9900-16. Diagnostic Code 9913 applies to dental service connection claims involving teeth. Compensation is only paid for loss of teeth due to loss of substance of body of the maxilla or mandible without loss of continuity (as a result of trauma) or disease such as osteomyelitis. Compensation is not available for loss of the alveolar process (the ridge on the surfaces of the upper (maxilla) and lower (mandible) jaws containing the tooth sockets) as a result of periodontal disease since such loss is not considered disabling. See Note, 38 C.F.R. § 4.150, Diagnostic Code 9913. VA regulations distinguish between “replaceable missing teeth” or periodontal disease and teeth lost as a result of “loss of substance of body of maxilla or mandible.” Simington v. West, 11 Vet. App. 41 (1998); 38 C.F.R. § 3.381. Replaceable missing teeth may be considered as service connected solely for the purpose of determining entitlement to dental examinations or outpatient dental treatment, but only the loss of teeth involving the loss of substance of body of either the maxilla or mandible (as described in 38 C.F.R. § 3.381) is considered compensable, and may be rated under the appropriate diagnostic codes. Thus, to warrant compensation for a dental disability, as opposed to outpatient dental treatment solely, the evidence must show not only that there was a dental trauma or disease (such as osteomyelitis), but that such trauma or disease caused a loss of substance of body of the maxilla or mandible resulting in a loss of teeth. VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). “New” evidence is evidence not previously submitted to agency decision makers and “material” evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, the credibility of the evidence is generally presumed. Cox v. Brown, 5 Vet. App. 95, 98 (1993); Justus v. Principi, 3 Vet. App. 510, 513 (1992). VA is required to review for newness and materiality only the evidence submitted by a claimant since the last final disallowance of the claim on any basis, whether a decision on the underlying merits or, a petition to reopen. Evans v. Brown, 9 Vet. App. 273, 283 (1996). In Shade v. Shinseki, 24 Vet. App. 100 (2010), the United States Court of Appeals for Veterans Claims (Court) held that § 3.159(c)(4) does not require new and material evidence as to each previously unproven element of a claim for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern where a prior denial was based on lack of current disability and nexus, the Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. Regardless of any RO determinations that new and material evidence has been submitted to reopen service connection, the Board must still determine whether new and material evidence has been submitted in this matter. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). Service treatment records reflect that in March 1967 the Veteran injured himself while performing his functions aboard ship. His lower lip was lacerated, teeth 9 and 10 were evulsed, and tooth 23 was fractured through the coronal portion. The Veteran initially claimed service connection for missing teeth from a mouth injury in March 1975. In his claim, he reported that in the summer of 1965 his upper and lower front teeth were knocked out by a machinery mishap. The Veteran underwent a VA examination in November 1975. He reported his injury, and from his description the examiner stated that he reported injuring teeth 8 through 11 and 23. Examination revealed moderately well-restored mouth with teeth 9 and 10 absent. He had full range of motion of the temporomandibular joint without pain or crepitus. There was a satisfactory bridge replacing the missing maxillary incisors and an esthetic crown on 23. In a March 1976 rating decision, service connection for residuals of a mouth injury was granted, but the decision stated that no specific dental rating was claimed. The Board construes this as a denial based on a finding of a lack of a current disability for compensation purposes. The Veteran neither appealed this decision nor submitted new evidence within the one-year appeal period, and the decision therefore became final. A May 1976 dental rating decision awarded service connection for the purposes of outpatient treatment only, as is available for dental disabilities ineligible for compensation. See 38 C.F.R. § 17.161. The Veteran underwent a VA examination in November 2010. The examiner noted that the record already reflected that he was service connected for treatment purposes due to trauma affecting teeth 9, 10, and 23. The examiner noted that the teeth were currently very well-restored, and no care was needed. There was no malunion, nonunion, or loss of bone in the mandible, maxilla, or the hard palate, and there was no evidence of osteomyelitis, osteoradionecrosis, or limitation of motion at the temporomandibular articulation. At his March 2020 hearing, the Veteran’s representative appeared to be arguing for service connection for treatment purposes only, which have already been granted in a May 1976 rating decision. This is a one-time benefit. The Veteran described recent dental work that had been performed. The Board finds that the evidence received since the final March 1976 rating decision is essentially cumulative of the evidence previously of record regarding the basis of the prior denial, lack of a current dental disability for VA compensation purposes. The Veteran’s statements and records essentially recount the evidence as was presented in his service treatment records and at his November 1975 VA examination. There is no new information or indication that the Veteran’s claimed disability consists of loss of substance of body of the maxilla or mandible, and as such it cannot be considered a current disability for VA compensation purposes. To the extent that the Veteran’s representative characterizes his appeal as one for service connection for treatment purposes only, such an appeal is dismissed as moot, having been fully granted in a May 1976 rating decision. As the evidence is essentially cumulative, the appeal to reopen the Veteran’s claim of compensatory service connection is denied. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. 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. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 1. Entitlement to a compensable evaluation for residuals of a laceration and puncture of the lower lip The Veteran’s disability is currently rated as a scar or disfigurement of the head, face, or neck under 38 C.F.R. § 4.118, Diagnostic Code 7800. Ratings under this code are based in part on characters of disfigurement. The eight characteristics of disfigurement for purposes of evaluation under this code are: (1) a scar 5 or more inches in length; (2) a scar at least one-quarter inch wide at its widest part; (3) surface contour of scar elevated or depressed on palpation; (4) a scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding six square inches; (6) abnormal skin texture (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches; (7) underlying soft tissue missing in an area exceeding six square inches; and (8) skin indurated and inflexible in an area exceeding six square inches. Scars with one characteristic of disfigurement warrant a 10 percent rating. A 30 percent rating is warranted for scars or disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. A 50 percent rating is warranted for scars or disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or with four or five characteristics of disfigurement. A maximum rating of 80 percent is warranted for scars or disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or with six or more characteristics of disfigurement. Unstable or painful scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7804. A 10 percent rating is warranted for 1 or 2 such scars, a 20 percent rating is warranted for 3 or 4 such scars, and a 30 percent rating is warranted for 5 or more such scars. If one or more scars are both painful and unstable, 10 percent is to be added to the total rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Codes 7800 and 7804 were not changed by these amendments. The Veteran underwent a VA examination in November 2012. The examiner noted two scars on the lower lip, 4.5 and 5 centimeters long and both less than a quarter centimeter wide. The scar was neither painful nor unstable. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation or texture. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. There was no resulting limitation of function or functional impairment. The Veteran underwent another VA examination in August 2016. The examiner diagnosed two scars of the right lower lip, 5 and 4.5 centimeters long, both 0.25 centimeters wide. The scars were neither painful nor unstable. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation or texture. There was no gross distortion or assymetry of the facial features. There was no visible or palpable tissue loss. There were traces of other scars on the lower lip and chin which were too faint to measure. There was no functional limitation or impact of the scars. At his March 2020 hearing, the Veteran stated that his teeth bothered him, but his lip did not, and he was satisfied with a noncompensable rating. He stated that his lip scar was painful when he bit his lip. The Board finds that a 10 percent rating is warranted for the Veteran’s lower lip residuals based on the pain he reported from biting the scars at his March 2020 hearing. A 10 percent rating is warranted under Diagnostic Code 7804 based on such pain from two scars. The Board further finds that a rating in excess of 10 percent is not warranted. Higher ratings are available for unstable scars, pain in more than two scars, visible or palpable tissue loss, gross distortion or asymmetry of features, or characteristics of disfigurement. There is no evidence of such symptoms. As such, an evaluation of 10 percent, but not in excess thereof, is warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to an initial compensable evaluation for bilateral hearing loss 3. Entitlement to an initial evaluation in excess of 10 percent for tinnitus In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. 38 C.F.R. § 4.85. Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of pure tone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a controlled speech discrimination test. The horizontal columns in Table VI represent 9 categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the pure tone decibel loss. The percentage evaluation is found from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation for the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level V and the poorer ear had a numeric designation of Level VII the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. Regulations also provide that in cases of exceptional hearing loss, i.e., when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that when the pure tone threshold is 30 decibels or less at 1000 hertz and 70 decibels or more at 2000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIA, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. The Veteran’s tinnitus is rated under 38 C.F.R. § 4.87, Diagnostic Code 6260. His current 10 percent rating is warranted for recurrent tinnitus and is the maximum schedular rating available. Diagnostic Code 6260 limits a veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. In a March 2013 statement, the Veteran’s wife stated that his hearing causes problems at work and that he is always asking her to repeat things. The Veteran underwent a VA examination in April 2013. He reported difficulty hearing, having to face speakers, and asking for repetition. He reported occasional tinnitus. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 40 35 50 35 LEFT 10 30 30 45 28.75 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. He was diagnosed with bilateral sensorineural hearing loss and tinnitus. The examiner noted that hearing loss caused functional impact of forcing him to face speakers and asking for repetition and that tinnitus did not cause functional impact. VA treatment records reflect that in June 2016 the Veteran reported difficulty with his hearing aids. He reported difficulty hearing with background noise or multiple talkers. He reported tinnitus rated at 3/10 that regularly interrupted his sleep. Specific pure tone thresholds were not included in the records, but the audiologist described bilateral hearing within normal limits through 1000 hertz sloping to a mild to moderately severe sensorineural hearing loss. Word recognition testing with 92 percent in both ears. There were no significant changes since 2013 testing. The Veteran underwent another VA examination in July 2016. He reported that he cannot always hear people and needs to ask for repetition in a restaurant situation. He reported tinnitus that he described as distracting. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 25 45 45 50 41.25 LEFT 15 35 35 50 33.75 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 100 percent in the left ear. He was diagnosed with bilateral sensorineural hearing loss. In a March 2020 statement associated with his application for a TDIU, the Veteran reported that his hearing loss had become much worse over the past 4-5 years. At his March 2020 hearing, the Veteran stated that his tinnitus was present in both ears more often than not. He stated that it made it really hard to hear and he could not even understand his wife. He reported that he often had to ask others to repeat themselves. His representative argued for a higher rating for tinnitus under DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995), a case that applies to musculoskeletal disabilities rated on the basis of limitation of motion. It is unclear on what basis the case would be applicable to the Veteran’s ratings. The representative further argued that extraschedular ratings were warranted for tinnitus and hearing loss because of the way that tinnitus interfered with the Veteran’s hearing. In a June 2020 statement, the Veteran’s wife stated that she continually yells so he can hear her. The Board finds that a compensable evaluation is not warranted for the Veteran’s hearing loss. Taking his highest pure tone thresholds and his lowest speech discrimination scores, Table VI yields Level I hearing loss in each ear. Under Table VII, compensable ratings are not available when both ears are less than Level IV. Moreover, there is no evidence that the Veteran exhibited exceptional hearing loss as defined by 38 C.F.R. § 4.86. For these reasons, a compensable rating is not warranted for the Veteran’s hearing loss. The Board further finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s tinnitus. His current rating, the maximum schedular rating allowed, is warranted for recurrent tinnitus. The only symptoms he reports fall under either the definition of the recurrent tinnitus explicitly contemplated by the criteria for her current rating, or the logical consequences of recurrent tinnitus, specifically resulting difficulties with hearing and sleeping. He has not otherwise identified any way in which his tinnitus is unusual and so warrants a higher rating than the vast majority of veterans experiencing his disability. For these reasons, the Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s tinnitus. At his March 2020 hearing, the Veteran’s representative claimed that hearing loss and tinnitus warranted an extraschedular rating. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” 38 C.F.R. § 3.321(b)(1) (related factors include “marked interference with employment” and “frequent periods of hospitalization”). When the rating schedule is inadequate to evaluate a claimant’s disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step—a determination of whether, to accord justice, the claimant’s disability picture requires the assignment of an extraschedular rating. Id. Specifically applicable to hearing loss and tinnitus, the Board has considered the Court’s holding in Martinak v. Nicholson, 21 Vet. App. 447 (2007). In that decision, the Court noted that, unlike the rating schedule for hearing loss, the extraschedular provisions did not rely exclusively on objective test results to determine whether referral for an extraschedular rating was warranted. The Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. In this case, the impairments attributed to the Veteran’s hearing loss and tinnitus are difficulty understanding speech and hearing ringing in his ears. The Veteran’s wife reports that he is always asking her to repeat things. The Veteran reported in April 2013 that he had to ask people to repeat themselves. In June 2016, the Veteran reported difficulty hearing in background noise or multiple speakers, and that the ringing in his ears interrupted his sleep. At the March 2020 Board hearing, the Veteran reported that his hearing loss made it really hard to hear and he could not even understand his wife. He reported that he often had to ask others to repeat themselves. These impairments are all explicitly contemplated by the rating criteria, which rate for impaired hearing acuity, impaired speech recognition, and tinnitus (ringing in the ears). There is no description of impairments that are not contemplated by the rating criteria. In view of the circumstances, the Board finds that the rating schedule is adequate, and that referral for extraschedular consideration is not warranted under the circumstances of this case. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. 4. Entitlement to an initial evaluation in excess of 30 percent for an acquired psychiatric disability, to include PTSD Diagnostic Code 9411 of 38 C.F.R. § 4.130 specifically addresses PTSD; however, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, the Veteran’s current 30 percent rating is warranted for 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Veteran underwent a VA examination in November 2010. He reported that he has highs and lows, being either very happy or depressed and irritable. He reported that his medication had somewhat stabilized his mood. He reported paranoia. He reported getting so upset with others that he feels he could hurt them, but he denied any physical altercations. He described his moods as controllable but still constant. He reported excessive sleep, 10-11 hours per night. He reported lack of enthusiasm. He reported constant worry. He stated that he was forced to retire from the real estate business in 2009. He stated that he was currently a volunteer patrol officer for the sheriff’s office one day per week. He reported that his current marriage was pretty good. He had minimal contact with his adult children from his first marriage. He was diagnosed with a mood disorder with a moderate to severe impact on his past work environments. In a December 2010 statement, the Veteran’s sister stated that he takes medication for mood control, anxiety, and depression. She reported that he changed jobs often, had a poor relationship with his children, and never seemed to have any long-term friends. She noticed that he had difficulty focusing and was easily and often distracted. VA treatment records reflect that in February 2011 the Veteran reported that he was an officer, an ordained minister, and a victims’ services worker. He reported two straight weeks of nightmares after his last mental health evaluation. He reported that his relatives feel uncomfortable around him because of his angry outbursts, which also caused him to lose almost every job he has had. He reported improvement in angry outbursts since beginning medication. He was diagnosed with PTSD and depressive disorder. In June 2011 he reported that his medications take the edge off and he does not get irritated with too much anymore. He denied suicidal thinking or homicidal ideation. He reported being easily distracted. He stated that his sleep was pretty good. In a June 2011 statement, the Veteran reported that he has never been able to hold down a job for any extended period except when working for his wife. He stated that his medication did not help but a service dog calmed him. In a second June 2011 statement, he reported serious anxiety issues, including twitching, whistling, apprehension, and a lot of worrying. In an accompanying statement, his wife reported that he has never been able to maintain long-term employment. She reported he experiences terrible dreams during which he fights and kicks while asleep. She reported he exhibits severe depression. VA treatment records reflect that in August 2011 the Veteran reported that he was doing pretty good. He reported that he continued to volunteer as an ordained minister and as a victims’ services worker. He reported taking classes to specialize in domestic violence victims. In February 2012 he reported that he was doing pretty good. He reported that his wife was diagnosed with Alzheimer’s. He reported that he was still looking for work. He reported a “little bit” of depression with decreased interest in daily activities, low energy, good concentration, and feelings of worthlessness. He reported nightmares and flashbacks. He was diagnosed with PTSD and depressive disorder. In June 2012 he reported that he was doing a little better and had been offered a couple of jobs. He reported an improvement in mood and attitude since using a CPAP machine. In December 2012 he reported nightmares. In February 2013 he reported nightmares three times per week, irritability, lack of focus, lack of motivation, and financial stress. In a March 2013 statement, the Veteran’s wife stated that he had terrible dreams that woke them both up on a regular basis. VA treatment records reflect that in May 2013 the Veteran reported stress due to his wife’s dementia. He reported fewer nightmares, less hopelessness, and more motivation. In October 2013 he reported that he had been doing well and was sleeping 8 hours per night with fewer nightmares. He reported a little hopelessness. In January 2014 he reported hopelessness, lack of motivation, fatigue, and inability to focus. In May 2014 he reported less anxiety, fewer nightmares, and 8-9 hours of sleep per night. In October 2014 he reported 9.5 hours of sleep per night, waking up with nightmares throughout. He reported hopelessness, irritability, and isolating. In December 2014 he stated that he was doing about the same. He reported sleeping 7 hours per night without sleep difficulties beyond nightmares 3-4 times per week. He reported flashbacks, excessive worry, tearfulness, and lack of motivation. In March 2015 he reported flashbacks triggered by filing his PTSD paperwork. He denied hopelessness, irritability, or excessive worrying. In April 2015, he reported a history of passive suicidal ideation but denied current suicidal ideation, plan, or intent. He denied any history of attempts. In July 2015 he reported that he was coping better through his group therapy. He was diagnosed with mild PTSD and depressive disorder in remission. In November 2015 he reported that he was doing well and denied any sleep difficulties, though he reported occasional nightmares. He reported a lack of motivation. In April 2016 he reported he was not doing well. He stated that he became suicidal after hurting his wife by engaging in inappropriate conversations online. He reported hopelessness, lack of motivation, tearfulness, isolation, and worry. In July 2016 he reported doing well and denied sleep difficulties. The Veteran underwent another VA examination in August 2016. He reported the status of his current 34-year marriage as fair. He was estranged from his adult children from a previous marriage. He reported that he regularly attends church. He stated that he was on the security team at church but did not engage with others beyond pleasantries. He reported that he does very little with others apart from his wife. He stated that he had a few acquaintances but would not call them friends. He reported that he spends time in his office watching television, using the computer, or with his dog. He reported that he used to volunteer as a chaplain with the sheriff’s office. He reported that he currently works part-time selling real estate with his wife, 2-4 hours per week. He reported that he attended college but did not graduate, and he never learned a trade. The examiner noted symptoms of anxiety, suspiciousness, and chronic sleep impairment. Mood was unremarkable and affect was full. His thinking was clear, logical, and goal directed. He was diagnosed with PTSD productive of 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 which are controlled by medication. The examiner explained that the severity of the Veteran’s PTSD appeared mild at the current time. The examiner noted that he reported instability in his work for most of his adult life, but it was unclear why, i.e., lack of job skills or training versus mental health issues. VA treatment records reflect that in October 2016 the Veteran reported stress over the process of applying for disability compensation. He reported 6-7 hours of sleep per night with occasional nightmares. In November 2016 he reported return of re-experiencing and social isolation. He was diagnosed with PTSD and a history of recurrent depression in partial remission. He was instructed in some therapeutic skills, and in December 2016 he cancelled his follow-up appointment stating that he was doing much better since practicing the skills. In January 2017 he reported that he continued to struggle with awaiting the results of his VA disability claim. He reported adequate sleep. His nurse practitioner diagnosed chronic PTSD and depressive disorder and noted that he appeared to be stable and doing well with current treatment. In April 2017 he reported mild depression since having a pacemaker installed. In September 2017 he reported that he was in a bad mood because new flooring was being installed in his home. In December 2017 he reported a poor mood due to an accident in which his dog was paralyzed. In June 2018 he reported depression and loss of sleep. He stated he was angry because he was not allowed to bring his service dog into Costco. In September 2018 he reported that he was pretty depressed and unhappy. He reported that he had three job interviews in the past week but felt unemployable. He reported that he was active in martial arts and taught self-defense to the elderly, women, and teens. In December 2018 he reported that he was a little worried about being reclusive. In a February 2019 statement, the Veteran’s wife reported that his PTSD controls his life, forcing him to re-live his experiences on a daily basis. She reported severely inappropriate behavior, inability to remember basic information, severe confusion and disorientation, and inability to care for himself. She reported irrational speech, irritability, depression, panic attacks, inability to control impulses, near-violent episodes, and neglecting self-care. She reported that he could not handle stress or maintain relationships. She reported that he could not keep a job for more than a few weeks. She stated that they cannot sleep in the same bed because he thrashes about from nightmares. VA treatment records reflect that in March 2019 the Veteran reported a terrible mood and depression. He reported an incident of road rage where he approached another car and tapped on the glass, scaring the other driver, who sped off. He reported that he was only sleeping a couple of hours at a time. In June 2019 he reported he was about the same, maybe a little worse. He reported anxiety and poor sleep and appetite. He reported isolation and difficulty shutting off thoughts and focusing. In September 2019 he reported having a tough time since his dog died a few weeks before. In December 2019 he reported a worsened mood during the holiday season and terrible dreams. He reported panic attacks. He stated he was getting along better with his wife. In a March 2020 statement associated with his application for a TDIU, the Veteran stated that his PTSD and depression had worsened. He attributed this worsening to exposure to herbicide agents, and provided literature showing a link between such exposure and dementia in patients with PTSD. In March 2020 he reported that his mood was not very good. He stated he was laid off from his volunteer position as church security head. At his March 2020 hearing, the Veteran reported that his problems with memory had worsened. He described a few jobs he tried that did not work out because he did not like being micromanaged, he was not making enough money, or he became too distracted. He stated that he did not have any friends. He stated that he was afraid to go out since his dog died. He stated that when he did go out to a restaurant, he always had to sit facing a door. He reported poor judgment, specifically buying a lot of things online that he does not need. Additionally, the Veteran and his representative argued that VA erroneously relied heavily on a statement submitted by his wife. He explained that at the time of the statement they were undergoing marriage counseling and were constantly fighting. This argument is confusing, as the September 2019 statement of the case did not rely at all on the statements of his wife. Indeed, as explained in the statement of the case, her letter was described as unreliable because the symptoms she described were more severe than any symptoms evident in his treatment records. In arguing that the Board should disregard his wife’s statement, the Veteran is arguing against his own interest. In a June 2020 statement, the Veteran’s wife reported that his PTSD was severe and chronic. She reported that he was hypervigilant and had episodes of rage. She reported that she has to remind him of things he needs to do. She reported that he has become less able to take care of himself. VA treatment records reflect that in June 2020 the Veteran reported that his mood was about the same with some depression, especially about the news. In September 2020 he reported he was doing pretty well despite a terrible mood and memory trouble. In December 2020 he reported irritability due to his memory problems. After a review of all of the evidence, the Board finds that the criteria for a rating of 70 percent are met; however, the criteria for a total rating are not met. With reference to the evidence set out above, the Board finds that the evidence substantiates deficiencies in family relations (estranged relationship with children), work (inability to adapt to work environment), and mood (chronic depression, anxiety, panic, suspiciousness). While there is mixed evidence on the remaining areas, there is evidence showing problems with focus, distraction, confusion, and memory. Accordingly, the Board finds that there are deficiencies in thinking. Moreover, the Veteran testified that his judgment is compromised, as he has been buying things he did not need. With resolution of all reasonable doubt in favor of the claim, the Board finds that there are deficiencies in most areas, and that the criteria for a rating of 70 percent are met. Despite the finding that there are deficiencies in most areas, the Board finds that there is not total occupational impairment and total social impairment. The Veteran retains the ability to function in a social environment with the noted deficiencies. Entitlement to a rating of 100 percent for a mental disability requires symptoms of the type and degree representative of serious impairments of thought, memory, communication, behavior, and orientation, such as to result in total social impairment and total occupational impairment. Here, the Board finds that the gross impairment of behavior resulting in severe disorientation, which is contemplated by the 100 percent rating criteria, is simply not substantiated. In sum, the Board finds that the service-connected mental disability is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but is not manifest by total occupational and social impairment. In light of these findings of fact, the Board concludes that a disability rating of 70 percent, but not higher is warranted for the service-connected mental disability. In reaching the conclusion that a total rating is not warranted, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim to that extent, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. 5. Entitlement to an effective date earlier than October 15, 2010, for an award of service connection for PTSD Generally, the effective date of an award of a service connection claim is the date of receipt of a claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Under regulations applicable prior to March 24, 2015, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant may be considered an informal claim. An informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a) (2014). VA received the Veteran’s claim of service connection for PTSD on October 15, 2010. His claims file does not contain any communication prior to that date indicating an intent to claim service connection for any mental health disability. Furthermore, apart from raising the effective date at his March 2020 hearing, there has been no communication from the Veteran or his representative regarding this issue. At no time has the Veteran or his representative explained why they believe he is entitled to an earlier effective date under the law. The fact that the Veteran may have had a diagnosis of PTSD prior to the date of claim, or that he may have symptoms of PTSD prior to the date of claim, or that there may have been treatment records in VA’s possession that may have substantiated the existence of PTSD prior to the date of claim, does not entitle the Veteran to an effective date earlier than the date of claim. It is the later of the date entitlement arose and the date of claim which governs. The presence of VA treatment records can only qualify as the date of claim where service connection has already been granted and an increased rating is sought. 38 C.F.R. § 3.157 (in effect prior to March 24, 2015). For these reasons, the Board finds that an effective date earlier than October 15, 2010, is not warranted for an award of service connection for PTSD. 6. Entitlement to a TDIU Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation has been defined as “an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran’s earned annual income.” Faust v. West, 13 Vet. App. 342 (2000). When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991) (citing Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975)). In making this determination, consideration may be given to factors such as the veteran’s level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran is totally disabled if his service-connected disability or combination of service-connected disabilities is rated at 100 percent pursuant to the Schedule for Rating Disabilities. 38 C.F.R. § 3.340(a)(2). Even if a veteran is less than 100 percent disabled, he still is deemed totally disabled under the Schedule for Rating Disabilities if he satisfies two requirements. 38 C.F.R. § 4.16(a). First, the veteran must meet a minimum percent evaluation. If he has one service-connected disability, it must be evaluated at 60 percent or more. If he has two or more service-connected disabilities, at least one disability must be evaluated at 40 percent or more and the combined evaluation of all the disabilities must be 70 percent or more. The following will be considered as one disability with respect to the minimum percent evaluation: (1) disabilities of one or both upper extremities or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system (e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric), (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Second, the veteran must be found to be unable to secure and follow a substantially gainful occupation as a result of his service-connected disability or disabilities. Id. Where a veteran does not meet the percentage evaluation requirements under 4.16(a), he still may be deemed totally disabled on an extraschedular basis under 38 C.F.R. § 4.16(b) when the evidence nonetheless indicates that the veteran is unemployable by reason of his service-connected disabilities. Under such circumstance the matter is referred to the Director of the Compensation and Pension Service (“Director”) for consideration. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Extraschedular TDIU consideration requires contemplation of the following factors: severity of the veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Although the Board does not have the authority to award an extraschedular TDIU prior to referral to the Director, the Board has jurisdiction to review and award extraschedular ratings in claims that have been denied by the Director. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015). The fact that a veteran is in receipt of a combined schedular rating of 100 percent does not preclude the availability of a TDIU. Although no additional disability compensation may be paid when a total schedular rating is already in effect, a separate award of a TDIU predicated on a single disability may form the basis for an award of SMC, and thus must be considered by the Board. Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). In determining whether a TDIU is warranted, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In his TDIU application received by VA in November 2012, the Veteran reported that he was rendered unemployable by his PTSD and diabetes beginning in 2006. He reported various jobs in sales for several months in 2008, most of 2009, and one month in 2012. In a January 2013 addendum opinion, a VA examiner opined that the Veteran’s diabetes mellitus did not prevent him from engaging in sedentary employment with position changes every 30 minutes as needed. The Veteran submitted a second TDIU application in March 2020. He stated that he had been rendered unemployable since 2012 by his diabetes, hearing loss, PTSD, COPD, and basal cell carcinoma. In an accompanying statement, the Veteran stated that in the past five years he worked 3-4 hours per week assisting his wife in her work in an administrative capacity. He stated that he believed that because of his conditions, the only jobs he can perform are those he can do on a computer. He believed that he would be able to work from home. He reported that he completed high school and three years of college. He stated that he trained to become a pastor and a law enforcement chaplain. He stated he worked with several groups in domestic violence and abuse. He reported that he continuously trained in the martial arts and held self-defense classes for teens and seniors. In the abovementioned March 2020 statement the Veteran also listed many other conditions that he believed were related to his exposure to herbicide agents, including Parkinson’s disease, Alzheimer’s, a brain tumor, nerve damage, heart conditions, mini-strokes, sexual dysfunction, hypothyroidism, and a thyroid nodule. These disabilities are not service connected and are beyond the scope of this decision. They may not be considered as a basis for a TDIU. At his March 2020 hearing, the Veteran’s representative argued that even if he did not meet the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a), referral for an extraschedular TDIU under § 4.16(b) was warranted, and such an extraschedular TDIU should be effective in 2012. In a March 2020 letter, the Veteran’s VA treating physician stated that he might be unemployable due to his multiple chronic medical and mental conditions including severe COPD, cognitive impairment, Parkinson’s disease, diabetes, heart block, and PTSD. After implementation of this decision, for the duration of the appeal period the Veteran will be in receipt of a 70 percent evaluation for PTSD, a 20 percent evaluation for diabetes mellitus, a 10 percent evaluation for residuals of a lower lip laceration, a 10 percent evaluation for tinnitus, and a noncompensable evaluation for hearing loss. His combined schedular rating is therefore 70 percent until March 2020, at which time he is also in receipt of four additional 20 percent ratings for diabetic neuropathy in each extremity. The combined rating is 80 percent prior to March 8, 2020, and 90 percent since March 8, 2020. He thus meets the eligibility threshold for a schedular TDIU under 38 C.F.R. § 4.16(a) for the entire period. The Board finds that the evidence is at least in equipoise as to whether the Veteran’s service-connected disabilities have rendered him unemployable or unable to secure and follow a substantially gainful occupation. Despite his ability to maintain social relationships and perform volunteer work, the stress brought on by his PTSD coupled with his physical weakness from his diabetes renders him unable to perform most jobs. Specifically, his treatment records establish that he is unable to function in a worklike setting due to his difficulty working with others and respecting authority. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s combined service-connected disabilities have rendered him unemployable or unable to secure and follow a substantially gainful occupation. A TDIU is therefore granted for the entire period. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. L. CRAMP Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Gallagher, 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.