Citation Nr: 21027850 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 12-35 441 DATE: May 7, 2021 ORDER Entitlement to a 70 percent rating, but no higher, for posttraumatic stress disorder with panic disorder, other specified sleep-wake disorder, somatic symptoms disorder and conversion disorder (acquired psychiatric disorder) from August 11, 2011, is granted. Entitlement to a 50 percent rating, but no higher, from December 30, 2010, for migraine headaches associated with a traumatic brain injury (TBI) is granted. Entitlement to an extraschedular rating in excess of 10 percent for tinnitus, associated with TBI, is denied. Entitlement to a 10 percent rating, but no higher, for the cognitive residuals of a TBI from December 20, 2010, is granted. Entitlement to an initial rating in excess of 10 percent for a left hip strain, based on limitation of flexion, is denied. Entitlement to an initial compensable rating for left hip strain, based on limitation of abduction or adduction, is denied. Entitlement to service connection of a back disability is denied. Entitlement to special monthly compensation in excess of level K, for loss of use of a creative organ, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) from December 30, 2010, to April 15, 2014, is granted. FINDINGS OF FACT 1. From August 11, 2011, the preponderance of the evidence shows that the Veteran's acquired psychiatric disorder was productive of occupational and social impairment with deficiencies in most areas but not total occupational and social impairment. 2. From December 30, 2010, the Veteran's migraine headaches associated with a TBI result in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. The degree of actual current impairment caused by the Veteran's tinnitus is adequately compensated for by the schedular rating assigned for the entire period on appeal. 4. From December 20, 2010, the preponderance of the evidence shows that the TBI cognitive residuals is manifested by no more than a facet of "1" in each of the 10 cognitive facets (disturbances in memory, attention, concentration and executive function, judgment, social interaction, orientation, motor activity, visual and spatial orientation, neurobehavioral effects, communication, consciousness, and other subjective symptoms) and it does not cause dysfunction distinct from his already service-connected disabilities. 5. The Veteran's left hip strain has not resulted in at least flexion limited to 30 degrees or less even when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 6. The Veteran's left hip strain has not resulted in at least adduction preventing him from crossing his legs, or abduction with loss of motion beyond 10 degrees, or limitation of rotation such that he cannot toe-out beyond 15 degrees even when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 7. The preponderance of the evidence shows that a back disability was not present in service or until many years thereafter, it is not related to service or to an incident of service origin, it is not caused or aggravated by a service-connected disability, it is not an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illnesses of unknown etiology, or a diagnosable chronic multisymptom illness with a partially explained etiology. 8. The Veteran does not meet the criteria for any special monthly compensation beyond that assigned for loss of use of a creative organ under 38 U.S.C. § 1114 (k). 9. From December 30, 2010, to April 15, 2014, the Veteran's service-connected disabilities rendered him incapable of gainful employment. CONCLUSIONS OF LAW 1. From August 11, 2011, the criteria for a 70 percent disability rating, but no higher, for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 2. From December 30, 2010, the criteria for a 50 percent rating, but no higher, for the migraine headaches associated with a TBI have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.124a, DC 8100. 3. The criteria for an extraschedular rating for tinnitus have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.321, 4.1, 4.119, DC 6260. 4. From December 20, 2010, the criteria for a 10 percent rating, but no higher, for cognitive residuals of a TBI have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.124A, DC 8045. 5. The criteria for an initial rating in excess of 10 percent for left hip strain with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, DC 5252. 6. The criteria for an initial compensable rating for left hip strain with limitation of abduction or adduction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, DC 5253. 7. The criteria for service connection for a back disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1154(b), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. 8. The criteria for a higher rate of special monthly compensation have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.102, 3.350. 9. From December 30, 2010, to April 15, 2014, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2004 to March 2006. Initially, the Board of Veterans' Appeal (Board) notes that the Veteran initially requested a hearing before a Veterans Law Judge. That hearing was scheduled for June 2017. However, prior to the hearing, in a May 2017 statement, the Veteran requested that the hearing be cancelled. Therefore, adjudication of the appeal can go forward without a hearing. This matter has previously come before the Board in February 2018 and July 2020, at which time the issues remaining on appeal were remanded for further development. In the most recent decision/remand issued by the Board in July 2020, the Board also remanded the issues of service connection of a cervical spine disability, and a right hand rash/scar. In February 2021, a rating decision was issued which granted service connection of both disabilities claimed on appeal. As that constitutes a complete grant of the issue sought, those claims are no longer before the Board as part of this appeal. Also in in July 2020 the Board decision, it recharacterized the Veteran's claim for an increased rating for the migraine headaches associated with a TBI as only covering the period from December 30, 2010, to November 7, 2019. The Board finds that this characterization was in error. See Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); AB v. Brown, 6 Vet. App. 35 (1993). As is discussed in more detail below, as part of the prior remand, the Board requested opinions regarding seizure-like symptoms and sleep issues and whether the constituted a residual of TBI. In October 2020, the Veteran was afforded a VA examination which found other sleep-wake disorder, somatic symptoms disorder, and conversion disorder to be unrelated to his TBI, but rather were more likely than not psychiatric diagnoses associated with his service-connected PTSD. As such, in February 2021, the RO issued a rating decision which updated the Veteran's psychiatric disability to include these diagnoses. They are rated as part of the Veteran's service-connected psychiatric disability, and the Board has characterized the service-connected psychiatric disability to reflect the additional diagnoses. Post-Remand Compliance Initially, the Board finds that the post-remand development substantially complied with the Remands. The Board has reached this conclusion because it finds that the post-Remand VA examinations provide all needed information to rate the Veteran's service connected disabilities under all applicable rating criteria and adjudicate the service connection claims. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Board has reached this conclusion because it finds that while the appeal was in Remand status the RO obtained and associated with the record all identified and available medical records. See 38 U.S.C. § 5103A(b). Therefore, the Board finds that further delay by remanding the appeal to undertake additional development is not required. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by a Diagnostic Code. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Entitlement to an increased rating for an acquired psychiatric disorder from August 11, 2011 The Veteran is service connected for an acquired psychiatric disorder is rated as 50 percent disabling from August 11, 2011, to August 15, 2014, and 70 percent disabling thereafter. He seeks ratings in excess of those assigned. The Veteran's PTSD is rated under DC 9411, which compensates for posttraumatic stress disorder (PTSD), and applies the General Rating Formula for Mental Disorders. Under the Diagnostic Criteria, a 50 percent rating is assigned 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. This appeal was perfected to the Board prior to August 2014, and therefore the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) applies in this matter. Although later editions of the DSM have abandoned use of Global Assessment of Functioning (GAF) scores due to "conceptual lack of clarity" and "questionable psychometrics in routine practice," see Golden v. Shulkin, 29 Vet. App. 221, 224 (2018), GAF scores are to be considered in this matter as they are included in the DSM-IV analysis. In including these scores, where available, the Board recognizes that GAF scores are merely a factor to be considered in assessing the severity of a Veteran's psychiatric disability. Rather, symptoms should be the primary focus when assigning a rating for a psychiatric disorder as relying exclusively on the use of "numerical GAF scores as a shortcut for gauging psychiatric impairment ... would be error." Id., at 225-26. The Veteran filed his claim for an increased rating in August 2011. That month, the Veteran was afforded a VA examination in connection with his increased rating claim. His diagnoses of posttraumatic stress disorder (PTSD) and panic disorder without agoraphobia were confirmed. The Veteran was assigned a GAF (Score of 55, implying moderate symptoms. The examiner opined that the Veteran's symptoms combined to result in occupational and social impairment with reduced reliability and productivity. Symptoms included anxiety and suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss such as forgetting names, directions, or recent events; and disturbances of motivation or mood. He also was noted to experience PTSD symptoms including re-experiencing, avoidance, and hyperarousal. He was competent and capable of managing his own financial affairs. He appeared as alert, coherent, and fully oriented. Grooming was good. He was cooperative in manner and showed a full range of affect consistent with the topics discussed. Underlying mood seemed dysphoric and he showed no signs of a formal thought disorder. No cognitive deficits were noted, to include any cognitive deficits related to TBI. He was not employed, but was enrolled full time as a student, with no time lost from school in the prior 12 months; the Veteran reported that he did well in school with effort. He was divorced and lived with a roommate. Although he had endorsed some excessive drinking in the past, he did not report any such issues at that time. The Veteran submitted a private summary of care, dated October 2, 2014. In that report, the private psychiatrist reported a diagnosis of PTSD and parasomnia, not otherwise specified. Symptoms included intrusive recollections of prior trauma, numbing and avoidance (deemed very significant), and alterations in mood and cognitions. He had hypervigilance and difficulty falling asleep and maintaining attention. Stressors included financial stress due to unemployed status, and persistent stress related to ongoing adverse interactions with the National Guard, Army, and VA. He was noted ot be enrolled in classes at Colorado State University, although he did have social and occupational impairments. Symptoms affected his social and interpersonal interactions. He participated in meaningful therapy and medication management. In recent months his understanding of the nature and cause of his impairments had increased significantly. On October 23, 2014, the Veteran was afforded a new VA examination in connection with his claim. The examiner found occupational and social impairment in most areas. He reported difficulty maintaining employment due to psychiatric and physical issues. He was enrolled part time (6 to 9 credits per semester) at Colorado State University, and was on track to finish his Bachelor of Arts degree in psychology. He was married. He actively participated in psychiatric treatment through VA and a private psychiatrist. He had no legal issues. He denied alcohol or drug issues. Symptoms included depressed mood, anxiety, suspiciousness, panic attacks occurring more than once a week, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. He appeared for his examination as alert, coherent, fully oriented, and dressed in clean and causal (appropriate) clothes. He was polite and cooperative in manner. Thought processes were logical and goal oriented, with full range of affect consistent with the topics discussed. Underlying mood seemed mildly dysphoric. He denied thoughts of suicide and did not show any evidence of a formal thought disorder. In May 2017, the Veteran submitted an opinion from a private psychologist. The examiner found that the Veteran's disability should be rated 70 percent disabling from August 2011. In support of this, the psychologist stated that there was occupation and social impairment based on the fact that he had left a job in 2009 due to his acquired psychiatric disorder symptoms. Ongoing treatment records documented improvement. For example, in November 2015, he reported that he was dating a woman and it was "going okay." He had followed up with a new VA doctor, which had been helpful. He was clinically stable and doing better. In March 2016, he reported good sleep generally. School was going well that semester. Energy level was about the same and he continued to interact with friends through Facebook. His treating provider found him clinically stable and gradually doing better. In November 2019, the Veteran submitted a private TBI cognitive screening diagnostic form which found objective evidence of memory, attention, and executive functions impairments, as well as some social awkwardness, mild to moderate spatial orientation impairment, and headaches and anxiety tied to his traumatic event. In October 2020, the Veteran was again afforded a VA examination, he was diagnosed with PTSD, other specified sleep-wake disorder, somatic symptom disorder, conversion disorder (manifested by attacks or seizures and altered hearing). He also reported a history of attention deficit hyperactivity disorder (ADHD). The examiner declined to give a personality disorder diagnosis. The examiner stated that all identified mental health, cognitive and behavioral symptoms are due to non-TBI related mental health diagnoses, and none are due to TBI. At the time he was divorced with a 3-year-old son. He was still involved in court proceedings regarding his son's custody. He reported that a maternal Aunt in Ohio had physical custody, which he was fighting. He stated that his son had been in Colorado with him that past summer and that they spent time coloring, walking in the park, snuggling, and doing math. He anticipated seeing his son for Thanksgiving and Christmas, with plans to fly to pick him up and bring him home with him. He was also in a relationship, although he felt it was more of a friendship, and they did not live together. He lived in the mountains and attended school remotely. He enjoyed tech-based activities such as building computers, lasers, and doing research. He was presently completing a Master of Social Work degree program with projected completion in November 2020. He reported that he is a licensed Colorado investigator, with 4000 hours recognized by the state. He had not begun work with the license yet but hoped to couple with his social work degree in the future and hoped to work with Veterans as a forensic social worker with a private practice for Veteran advocacy. The examiner conducted a thorough review of the Veteran's complete medical history. Symptoms included anxiety, suspiciousness, panic attacks that occur weekly or less, chronic sleep impairment, mild memory loss, circumstantial or circumlocutory or stereotyped speech, impaired judgment, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships. He appeared well groomed and dressed appropriately. He made good eye contact. No abnormal movements or tremor were noted. He was cooperative and appeared forthcoming ans sincere in presentation. He reported an anxiety mood, and affect was congruent with mood, full, and reactive. Speech was mildly pressured and rapid with normal volume and pronunciation. Thought process was fluent, logical and goal directed with mild stuttering on emotional content. He showed no evidence of delusions or hallucinations. He was alert and oriented. He did not demonstrate any objective memory or attention concerns. He denied suicidal ideation plan or intent. The October 2020 examiner also considered the Veteran's complete medical record and opined that both the Veteran's sleep-wake disorder (to include sleep paralysis), somatic symptom disorder and conversion disorder, which accounted for his seizure-like symptoms, were also psychiatric diagnoses, which were more likely than not related to his PTSD. In light of this, the RO, in a February 2021 rating decision, recharacterized the Veteran's psychiatric disability to include these diagnoses as part of his PTSD. Tellingly, the Court has held that "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date." Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (discussing assignment of an effective date for a reduction in disability rating under Diagnostic Code 7528); see also Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014). (holding that a medical opinion can diagnose the presence of the condition and identify an earlier onset date based on preexisting symptoms). Therefore, when considering the frequency, severity, and duration of the Veteran's impairment to assess his disability picture and when resolving all reasonable doubt in his favor, the Board finds that the most probative evidence of record are the above examinations and treatment records that shows that the acquired psychiatric disorder adverse symptomatology approximates the criteria for a 70 percent rating at all times from August 11, 2011, because his adverse symptomatology includes, among other things, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss such as forgetting names, directions, or recent events, re-experiencing, avoidance, hyperarousal, intrusive recollections of prior trauma, numbing, avoidance, alterations in mood and cognitions/disturbances of motivation and mood/a depressed mood, hypervigilance, impaired judgment, impaired attention and executive functions, and circumstantial or circumlocutory/stereotyped speech. See 38 C.F.R. § 4.130; Owens, supra; Fenderson, supra; Hart, supra; Tatum, supra; Young, supra. However, the Board finds that the criteria for a higher rating of 100 percent are not met at any time from August 11, 2011. In this regard, the Board finds that at no period on appeal has the Veteran been shown to exhibit total occupational and social impairment, such that a 100 percent or total rating is warranted. Moreover, the Veteran has not shown any of the type of symptoms which would give rise to such a rating. Indeed, while he has not worked for most of the period on appeal, he has been enrolled in a bachelor's degree and subsequent master's degree program, with good results. He has a son over whom he reports having primary or shared custody. He is able to maintain conversation, generally behaves appropriately, and is capable of managing his own financial affairs. There is no evidence of gross impairment of thought processes or communication; he hasn't been found to have hallucinations or delusions. He's generally denied suicidal or homicidal ideation- in fact, he has significant professional plans for his future. He's not generally disoriented to time or place. He takes care of himself and manages basic hygiene. In all, the Board does not find evidence of total impairment. In reaching this conclusion, the Board does acknowledge that the Veteran does have deficiencies, but the greater weight of evidence demonstrates that it is to a degree less than that contemplated by a 100 percent rating. To the extent that the Veteran has any of the criteria for a 100 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes that his overall level of disability does not exceed the criteria for a 70 percent rating from August 11, 2011. Therefore, the Board finds that the criteria for a 100 percent rating are not met for the Veteran's acquired psychiatric disorder at any time from August 11, 2011, because his PTSD does not cause both total occupational and social impairment. See 38 C.F.R. § 4.130; Fenderson, supra; Hart, supra. In reaching all the above conclusions, the Board considered the doctrine of reasonable doubt. 38 U.S.C. § 5107(b). However, as the preponderance of the evidence is against the claim for a rating in excess of 70 percent for an acquired psychiatric disorder from August 11, 2011, the Board finds that the doctrine is not for application. See Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert, supra. Entitlement to an increased rating for headaches associated with TBI from December 30, 2010 The Veteran's migraine headaches, as associated with his TBI, are rated as 30 percent disabling from December 30, 2010, to November 7, 2019, and 50 percent disabling from November 7, 2019. He seeks a higher rating. The Veteran's migraine disorder is rated under DC 8100, which compensates for migraine headaches. Under the applicable rating criteria, a 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over last several months. A maximum 50 percent rating is assigned for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The Veteran was afforded a TBI examination in August 2011. At that time, he was noted to have headaches which started at the top of his head. His headaches occurred 2-3 times per month, lasting 24 hours, and with an intensity of 5-6 out of 10. He denied an olfactory aura. He complained of blurred vision, although he denied double vision. He complained of photophobia, phonophobia, dizziness, nausea, and vomiting. He also complained of mild left-side weakness during headaches. He denied problems with gait, speech, or mentation. He treated his headaches with over the counter medications. He asserted that 20 percent of his headaches were debilitating. In October 2014, he was again afforded a VA examination in connection with his claim. At that time, he reported some other headache issues related to his sleep issues but stated that he experienced migraines 5-6 times per month, treated with prescription and over-the-counter medication. Usually his headaches lasted about a half day but could last up to a whole day or even a day and a half. He reported "spots" in his vision, phono- and photophobia, and sensitivity to smells. He endorsed occasional nausea and vomiting, and stated that in the recent past, he had missed school on three separate occasions due to migraines. The examiner classified the Veteran's attacks as prostrating in nature, occurring once every month, although he did not find them to be "very prostrating or prolonged." His then-wife also noted that he had been required to drop an early class due to headaches, although the Veteran attributed that more to his sleep condition. At the subsequent December 2019 VA examination, the Veteran reported having problems with pulsing/throbbing head pain on both sides of the head. The Veteran reported that his headaches are accompanied by nausea, vomiting, sensitivity to light, sensitivity to sound, changes in vision (such as scotoma, flashes of light, tunnel vision), and sensory changes (such as feeling of pins and needles in extremities). It was noted that his headaches lasted less than 1-day. It was thereafter opined that not only did the Veteran have characteristic prostrating attacks occurring on an average once a month over last several months, but he also had very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. As noted above, the Court has held that "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date." Tatum, supra; Young, supra. Therefore, when considering the frequency, severity, and duration of the Veteran's impairment to assess his disability picture and when resolving all reasonable doubt in his favor, the Board finds that the most probative evidence of record are the above examinations and treatment records that shows that the migraine headaches associated with the TBI adverse symptomatology approximates the criteria for a 50 percent rating at all times from December 30, 2010, because his adverse symptomatology includes, among other things, very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. See 38 C.F.R. § 4.124a; Owens, supra; Fenderson, supra; Hart, supra; Tatum, supra; Young, supra. Entitlement to an extraschedular rating in excess of 10 percent for tinnitus associated with TBI The Veteran has been granted a maximum 10 percent schedular rating for tinnitus, as associated with his TBI. He seeks a rating in excess of that 10 percent on an extraschedular basis. The Board finds that the claim should be denied. Tinnitus is rated under DC 6260, which compensates for recurrent tinnitus with a maximum 10 percent rating. 38 C.F.R. § 4.87, DC 6260. In this regard, the Veteran is already in receipt of the maximum available rating for tinnitus, and the Board cannot assign a higher schedular rating as such a rating does not exist. Nonetheless, the Veteran has asserted that he should receive a rating in excess of 10 percent. To accord justice in the exceptional case where the criteria in VA's Rating Schedule are found to be inadequate, an extraschedular rating that is commensurate with the average earning capacity impairment caused by the service connected disability is warranted. 38 C.F.R. § 3.321 (b)(1). Such a rating is warranted when the case presents such an unusual disability picture with related factors such as marked interference with employment as to render impractical the application of the regular schedular standards. Id. When the Board finds that an extraschedular rating may be warranted based on the above factors, it cannot grant an extraschedular rating in the first instance. Anderson v. Shinseki, 23 Vet. App. 423, 428-429 (2009). Rather, it must remand the claim to the Agency of Original Jurisdiction (AOJ) for referral to the Director of Compensation Service (Director). See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The United States Court of Appeals for Veterans Claims (Court) has set out a three-part test, based on the language of 38 C.F.R. § 3.321 (b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. All three criteria must be met for referral for an extraschedular rating. Id. The Board has remanded this appeal so that the Director could issue an extraschedular decision in this matter. In February 2020, the Director issued an advisory opinion finding in which they concluded that, based on the evidence of record, there is no impairment in/of earning capacity due to exceptional or unusual factors related to marked interference with employment or frequent periods of hospitalization. Thus, they concluded that entitlement to an extraschedular rating is denied. Upon review of the Veteran's claims file, the Board concurs with the Director and finds that an extraschedular rating is not warranted in this matter. While the Veteran has not been employed throughout the claims period, he has been enrolled in multiple higher education programs, earning both a bachelor's and master's degree. His ability to carry out such work does not speak to any type of economic inadaptability specifically attributable to his tinnitus. Further, there is no evidence of frequent hospitalization. Beyond ringing in the Veteran's ears, there is no evidence to imply that his tinnitus symptoms are not addressed by the rating criteria. Further, to the extent that he has complained of other neurological or cognitive symptoms, the October 2020 VA psychiatric examination attributed those symptoms exclusively to his various psychiatric disabilities, and not to his tinnitus. In short, there is no evidence to support a finding that the Veteran's tinnitus symptoms are not addressed by the rating criteria, or that his tinnitus has resulted in an exceptional or unusual disability picture. Neither is there any evidence such an extraschedular rating is in the interest of justice. Therefore, at the claim fails the three criteria of Thun, the Board will deny an extraschedular rating for tinnitus. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Entitlement to an increased rating for the cognitive residuals of a TBI from December 20, 2010 The Veteran is in receipt of a 10 percent rating for the cognitive residuals of a TBI from December 20, 2010, with a non compensable rating from October 24, 2014, under the Diagnostic Code 8045 pursuant to 38 C.F.R. § 4.124a. As addressed herein, the Veteran's psychiatric symptoms are exclusively attributed to his various service-connected psychiatric disabilities and are included in the evaluation for those service-connected disabilities, above. He is also service-connected for tinnitus and headaches associated with TBI, the ratings for which have already been addressed above. He is also service-connected for erectile dysfunction, associated with TBI, the rating for which the Board addressed in its July 2020 decision. Moreover, the Board also finds that no further discussion of them is required except for those that are in appellate status. To this extent, the Board has addressed the Veteran's psychiatric and physical impairments associated with TBI, leaving it to consider any remaining cognitive impairment Diagnostic Code 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions include goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In each individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another DC, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table. In this case, the Veteran has not been assigned a separate evaluation for a distinct diagnosis of any disability other than vertigo because, as will be explained in more detail below, he does not have any other distinct diagnoses. VA is to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified." The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed in 38 C.F.R. § 4.124a, Diagnostic Code 8045, that are reported on an examination, VA is to evaluate under the most appropriate Diagnostic Code. Each condition is to be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" addresses 10 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." These facets are memory, attention, concentration and executive function, judgment, social interaction, orientation, motor activity, visual and spatial orientation, neurobehavioral effects, communication, consciousness, and other subjective symptoms. 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 assigned if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, a 70 percent evaluation is assigned if 3 is the highest level of evaluation for any facet. In this regard, it is important for the Veteran to understand that the evaluation of a TBI is highly multifaceted. The current version of Diagnostic Code 8045 contains the following notes: Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, 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 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" traumatic brain injury, which may appear in medical records, refer to a classification of a traumatic brain injury 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. Note (5): A veteran whose residuals of a traumatic brain injury are rated under a version of 38 C.F.R. § 4.124a, Diagnostic Code 8045, in effect before October 23, 2008, may request review under Diagnostic Code 8045, irrespective of whether his disability has worsened since the last review. VA will review that Veteran's disability rating to determine whether the Veteran may be entitled to a higher disability rating under Diagnostic Code 8045. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 C.F.R. § 3.114, if applicable. 38 C.F.R. § 4.124a, Diagnostic Code 8045. With the above criteria in mind, at the August 2011 VA examination his initial injury was deemed to be mild and the condition was stabilized. He showed no history of balance or coordination problems, autonomic dysfunction, numbness or paresthesias, other sensory changes, weakness or paralysis, mobility problems, ambulatory problems, malaise, bowel problems, vision problems, decreased sense of taste or smell, endocrine dysfunction, or cranial nerve dysfunction. He was noted to have headaches (addressed above). He complained of mild memory loss, but no such memory loss was objectively shown on testing. Judgment, social interaction, orientation, and visual spatial orientation were all normal. He was noted to have dizziness episodes 2-3 times per week, lasting seconds; and complained of complex partial seizures (diagnosed in 2006) occurring 8 times per month, lasting minutes. His only pain was due to headaches. He complained of fatigue. Sleep issues he attributed to his seizure disorder. He experienced anxiety when exposed to large groups of people. Memory impairment was mild, and he complained of decreased attention, difficulty concentrating, and difficulty with executive functions. He had some urinary incontinency, which did not require wearing of absorbent materials. He had erectile dysfunction. He complained of tinnitus and hearing loss, as well as expressive aphasia at times. Reflexes were generally hypoactive. Sensory testing was normal. Detailed motor testing showed active movement against full resistance on all planes. Despite the Veteran's assertions regarding symptoms, testing showed no objective evidence of autonomic nervous system impairment; gait abnormalities; imbalance or tremors; muscle atrophy or loss of muscle tone; spasticity or rigidity; fasciculations; cranial nerve dysfunction; hearing problems; endocrine dysfunctions; skin breakdown; vision problems; or other physical abnormalities. Cognitively, a Montreal Cognitive Assessment (MoCA) test score was 27/30, indicating no cognitive impairment. His only identified psychiatric symptoms was a mildly flattened affect. He complained of mild memory loss, occasionally inappropriate social interaction, and mildly impaired visual spatial orientation (described as difficulty reading maps or following directions, although he was able to use GPS devices without issue). Orientation and motor activity were completely normal. The examiner stated dizziness, hypersensitivity to sound, and fatigue mildly interfered with work, activities of daily living, family, or other relationships, although did not specify which symptoms or how they interfered. Neurobehavioral effects did not interfere with workplace or social interactions. Consciousness and communication were normal. On total, the examiner found that the Veteran's cognitive and social impairment were more likely than not due to his PTSD and should be rated under that criteria. At his contemporaneous PTSD examination, he was assessed for any cognitive deficits associated with TBI. He was administered a MOCA test and obtained a corrected raw score of 26 out of 30 possible points, which is not consistent with any residual deficits. The examiner concluded that no further neuropsychological assessment was needed at that time. Private records from November 2012 indicate episodes waking him from sleep and consisting of a buzzing sensation throughout his whole body with paralysis for 30-90 seconds and subsequent headache and fatigue. The possibility of atypical migraine was considered, as was a seizure disorder. No specific cognitive deficits were identified. He was alert and oriented with clear and coherent speech, normal motor and sensory findings, and normal cranial nerve testing. The physician noted that his symptoms could also be psychiatric in nature but suggested further neurological testing. In October 2014, he was afforded a PTSD examination. The examiner also reassessed the Veteran for possible cognitive residuals associated with his TBI. The examiner found that he did not show any cognitive deficits and stated that difficulties with concentration, distractibility, and "forgetfulness" are more likely than not part of his PTSD symptoms than any separate TBI residual. With the exception of memory/attention complaints which were more likely due to his PTSD than a TBI, all other cognitive facets (judgment, social interaction, orientation, visual spatial orientation, and neurobehavioral effects) were found to be normal or nonexistent. A TBI examination conducted at the same time found no cognitive effects other than headaches and anxiety and did not interfere with work or instrumental activities of daily living. All other facets were not found or were found to be normal. In November 2019, the Veteran submitted a private TBI cognitive screening diagnostic form which found objective evidence of memory, attention, and executive functions impairments, as well as some social awkwardness, mild to moderate spatial orientation impairment, and headaches and anxiety tied to his "traumatic event." In December 2019, the Veteran was afforded a new VA examination which found no memory, attention, concentration, or executive functioning impairments. Judgment was normal. Social interaction was occasionally inappropriate, attributable to panic attacks, which had increased frequency with social engagements, although he was able to work and attend school. He was always oriented. His motor activity was normal. Visual spatial orientation was mildly impaired, and described as feeling lost in unfamiliar surroundings, although able to figure out where he needs to go. He relied heavily on his GPS. Subjective symptoms included sleep difficulties, headaches, and anxiety. The examiner noted a history of a possible seizure disorder, but als noted that other records did not show such seizure activity. Neurobehavior effects included irritability. He had occasional word-finding difficulties although communication was generally good, and he was able to communicate quite complex ideas during the examination. Consciousness was normal. Physically, he experienced headaches. Functionally, headaches interfered with work or school, but no other symptoms contributed to functional deficiencies. The examiner stated that he could not attribute the Veteran's non-headache symptoms to PTSD or to TBI without resort to speculation. In October 2020, the Veteran was afforded a new VA examination to assess any residuals of TBI. Memory, attention, concentration, and executive functioning were normal. Judgment and social interaction deficiencies were not found. Orientation deficiencies were not found. Motor activity was normal. No visual spatial orientation deficiencies were reported. Subjective symptoms consisted exclusively of tinnitus, headaches, and sleep issues with auditory sensations. No neurobehavioral effects were reported. He was able to communicate by spoken and written language and comprehend spoken and written language. Consciousness was normal. The examiner deferred to a psychiatrist who conducted a contemporary mental health evaluation with regard to any unusual symptoms listed in the opinions. At the same time, the Veteran was again afforded a VA examination in connection with his PTSD claim, he was diagnosed with PTSD, other specified sleep-wake disorder, somatic symptom disorder, conversion disorder (manifested by attacks or seizures and altered hearing). He also reported a history of attention deficit hyperactivity disorder (ADHD). The examiner declined to give a personality disorder diagnosis. The examiner stated that all identified mental health, cognitive and behavioral symptoms are due to non-TBI related mental health diagnoses, and none are due to TBI. At that time, he reported that he was not taking any seizure medications, and that he had not had any daytime episodes for some time so he was not sure if he had seizures at all. He continued to have sleep paralysis, hypnopompic episodes fused into waking states, with buzzing sensations during REM sleep, which he states had been "misdiagnosed as seizures. The examiner noted issues with facets 1 (memory, attention, concentration, executive function) and 6 (visual spatial orientation), which were subjective or mild in nature and all due to mental health diagnoses as opposed to TBI. All other facets were normal. Most importantly, in October 2020, the examiner considered the Veteran's complete medical history and concluded that all identified mental health, cognitive and behavioral symptoms are due to non-TBI related mental health diagnoses, and none are due to TBI. Specifically, the psychiatrist stated that since 2008 the Veteran had seen multiple specialists to determine the etiology of seizure-like and sleep disturbance episodes. Various seizure disorders, narcolepsy, cataplexy, a cardiac or breathing issues were ruled out. Rather, the examiner determined that his condition was due to an "other specified sleep-wake disorder and/or a conversion disorder, both psychiatric in nature, and associated with his PTSD. Further, the psychiatrist reviewed the various facets of cognitive residuals of TBI. While some subjective complaints of memory, attention, concentration, and executive function were noted, there was no objective evidence of any impairment, and any that did exist was due exclusively to his mental health diagnoses. Likewise, social withdrawal and suspiciousness; mild visual spatial orientation issues; and any neurobehavioral effects were also all attributed to his mental health diagnoses. The examiner stated that no such symptoms were alone attributable to residuals of TBI. As noted above, the Court has held that "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date." Tatum, supra; Young, supra. Therefore, when considering the frequency, severity, and duration of the Veteran's impairment to assess his disability picture and when resolving all reasonable doubt in his favor, the Board finds that the most probative evidence of record is the August 2011 VA examiner's assignment to the Veteran of a facet of "1" for his visual spatial orientation facet, indicating that an examiner has found evidence such as mildly impaired and a facet of "1" for subjective symptoms facet, indicating that an examiner has found evidence of three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships even though all of the facets at that examination as well as at the subsequent VA examinations was "0." See Owens, supra; Tatum, supra; Young, supra. Therefore, the Board finds that the most probative evidence of record shows that the cognitive residuals of a TBI approximates the criteria for a 10 percent rating, but not higher, at all times from December 20, 2010, because his adverse symptomatology includes a facet of "1" but no higher at the above examinations. See 38 C.F.R. § 4.124a; Owens, supra; Fenderson, supra; Hart, supra; Tatum, supra; Young, supra. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim for more than a 10 percent rating, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Entitlement to an initial rating in excess of 10 percent for a left hip lost flexion and an initial compensable rating for left hip lost abduction or adduction The Veteran's left hip strain has been separately rated based on limitation of flexion at 10 percent and based on limitation of abduction or adduction as noncompensable. He seeks higher ratings for the hip disability. The Board finds the claims should be denied. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Moreover, the United States Court of Appeals for Veterans Claims (Court) in Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016) held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. Furthermore, in Jones Shinseki, 26 Vet. App. 56, 61-63 (2012) the Court held that the Board may not deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria. The Veteran's disability is rated on two planes of motion. Limitation of flexion is rated under DC 5252. A 10 percent rating is assigned for flexion limited to 45 degrees or more. Flexion limited to 30 degrees is assigned a 20 percent rating. flexion limited to 20 degrees is assigned a 30 percent rating. Finally, flexion of the thigh limited to 10 degrees or less is assigned a maximum 40 percent rating. 38 C.F.R. § 4.71a, DC 5252. Thigh impairment is rated under DC 5253. For a compensable (10 percent) rating under the applicable criteria, either limitation of rotation (described as cannot toe-out more than 15 degrees) or limitation of adduction (described as cannot cross legs) must be shown. Limitation of abduction, with motion lost beyond 10 degrees is assigned a 20 percent rating. 38 C.F.R. § 4.71a, DC 5253. The Veteran was afforded a VA examination in July 2009. Left hip flexion was to 125 degrees, with an additional 5 degrees un repetitive use. Abduction was to 35 degrees after repetitive use. Internal rotation was to 40 degrees. External rotation was to 15 degrees with an additional 5 degrees on repetitive use. There was no observed manifestation of pain during range of motion testing. The Veteran reported clicking in his hip, although no additional limits to range of motion could be attributed during periods of flare. The examiner did not note any objective evidence of change based on active vs. passive motion testing. His diagnosis was episodic hip strain. A new examination conducted in February 2012. He reported constant deep left lateral hip pain if carrying more than 75 pounds. Sometimes he stated that hip pain increased with the left leg crossed over the right knee after 10 to 15 minutes. If aggravated, he stated that it took several days to return to baseline. He denied flare-ups. Flexion was to 110 degrees with evidence of pain at 110 degrees. Extension was greater than 5 degrees without evidence of painful motion. Abduction was not lost beyond 10 degrees. He was not limited in his ability to cross his legs. He was able to toe-out beyond 15 degrees. No changes were reported on any plane of motion with repetitive use testing. He was noted ot have less movement than normal in the left hip/thigh. No localized tenderness was found. Muscle strength was normal on all movements. There was no evidence of ankylosis. He did not use an assistive device to ambulate. Private treatment records dated in January 2013 noted that the Veteran could produce 90 degrees of hip flexion with pain beginning at 90 degrees. Pain was described as a generalized ache with throbbing pain as well. In supine position he showed flexion to 105 degrees with overpressure, with pain at that limit. Extension was to 10 degrees with pain at 10 degrees. Abduction was to 35 degrees with pain at the terminal degree. External rotation was to 40 degrees. Internal rotation was to -5 degrees. Strength was limited to 3+ or 4 on flexion, abduction, extension, and internal rotation. No neurological symptoms were noted. He was prescribed stretching activities. Pain was described as 2/10 increasing to 4/10 if he crosses his legs for any length of time. He had stopped running due to his hip pain but did engage in dancing and yoga. In May 2017 he was afforded a new VA examination. His diagnosis of a left hip strain was confirmed. He denied flare ups. He denied any specific functional loss in that hip. Flexion was to 115 degrees. Abduction was to 30 degrees. Adduction was complete and full. External rotation was to 45 degrees and internal rotation was to 30 degrees. No objective evidence of pain was noted, and the Veteran did not report any subjective pain. Localized tenderness was not noted. There was no evidence of crepitus. No additional loss was found on repetition. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Additional factors contributing to the Veteran's disability consisted exclusively of less movement than normal, as found on examination. Muscle strength was normal. No ankylosis, either actual or functional was noted. He did not use any assistive devices to ambulate. The examiner opined that his condition did not impact his ability to perform any type of occupational task. Private treatment records from May 2018 noted chronic hip pain, but a normal gait. In December 2019, the Veteran was again afforded a VA examination. At that time his diagnosis of left hip strain was confirmed. He again denied flare-ups of his condition. He denied any functional loss or impairment of the joint. Flexion was complete and full to 125 degrees. Abduction was normal to 45 degrees; adduction was normal to 25 degrees. External and internal rotation, and extension were all complete and full. Pain was noted on examination on all planes of motion but did not contribute to any functional loss. There was no evidence of localized tenderness or crepitus. No additional loss was observed on repetitive use testing. Testing was completed in passive, active, weight-bearing, and non-weight bearing motion. Adduction was not limited such that the Veteran could not cross his legs. The examination was medically inconsistent with the veteran's statements regarding functional loss over time. Specifically, the examiner noted that, although the Veteran reported functional impact and loss with repeated use, the current examination and medical record findings were not consistent with the loss he reported. Essentially, the Veteran will have additional pain with repetitive use, but not any functional loss in terms of range of motion. Muscle strength was normal. There was no evidence of muscle atrophy or ankylosis. He did not use any assistive devices to ambulate. Private chiropractic records obtained since the time of the last remand show that the Veteran's hips are shifted .24 inches to the right, 1.17 inches forward, and his hips are not tilted. December 2012 private medical reports include consideration of hip joint imaging which did not show any arthritis. Initially, in adjudicating below whether the Veteran meets the criteria for a higher evaluation for his hip disorders the Board has not overlooked the Court's holdings in Sharp v. Shulkin, 29 Vet. App. 26 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016). Tellingly, the Board finds that the record is adequate to address the concerns raised by the Court in both these cases. Specifically, the Board finds that the post-Remand VA examination provides VA with medical opinions evidence adequate to rate the Veteran's hip when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups because the examiner specifically addressed each of these concerns. In light of the medical evidence, the Board finds that the claims should both be denied. Specifically, while the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), his functional losses do not equate to the criteria required for at least the next higher rating because flexion has not been limited to 30 degrees or less, there is no evidence that abduction is 10 degrees or less, no evidence adduction is limited such that he cannot cross his legs, and there evidence that limitation of rotation prevents him from toeing-out beyond 15 degrees. See 38 C.F.R. § 4.71a, DCs 5252, 5253; Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). In short, even when considering the Veteran's own lay statements and reports of limitations to include his reports of chronic pain, that pain did not result in limitation of movement such that higher ratings are warranted under the diagnostic code. Moreover, the Board finds the VA examiners opinions as to the Veteran's adverse symptomatology more probative than any lay claims from the appellant to the contrary even though his symptomatology is observable by a lay person because the examiner has medical training. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). The Board has also considered whether any other diagnostic code pertaining to the hip or thigh might provide for a higher rating based on the pathology of the Veteran's disability but finds that no such pathology exists. See Butt's, supra. In sum, the Board finds that the claim for a rating in excess of 10 percent based on limitation of flexion of the thigh, and a compensable rating based on limitation of abduction or adduction must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The Service Connection Claim Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this regard, to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The Court in Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014) held, in part, that the Board needs to always consider 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 in cases like the current appeal in which Veterans have served in the Persian Gulf since August 2, 1990. Therefore, the Board finds that it is also required to consider 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See 38 C.F.R. § 3.117 (d)(1) and (2) (a "Persian Gulf veteran" is defined as "a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. The "Southwest Asia theater of operations" includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations). In this regard, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or that became manifest to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. An "undiagnosed illness" is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least 6 months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least 3 months prior to diagnosis. 38 C.F.R. § 3.317 (a)(2)(i)(B)(3). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Ward v. Wilkie, 31 Vet. App. 233 (2019). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran seeks service connection of a back disability. The Board finds that the claim should be denied. As an initial matter, the Board recognizes a present diagnosis of intervertebral disc height at L5-S1 and mild lumbosacral sclerosis with mild lumbar spondylosis and a lumbar strain. A review of the Veteran's service treatment records does not reveal any specific incident, illness, or injury to his low back. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not sustain a disease or injury while on active duty that caused his current bilateral disability. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Likewise, the record does not show the Veteran being diagnosed with arthritis in the back in the first post-service year because the diagnosis of decrease in intervertebral disc height at L5-S1 and mild lumbosacral sclerosis with mild lumbar spondylosis does not appear in the record until December 2008, several years after he separated from active service. Therefore, the Board finds that the presumptions found at 38 C.F.R. § 3.309(a) do not help the Veteran establish service connection for a back disability. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. § 3.307. More importantly, the record does not show that the Veteran had a continued problem with a back disability in and since service. For his part, the Veteran asserts that his low back pain began in service and has continued to the present. However, as discussed above, service treatment records do not reveal any specific incident, illness, or injury to his low back. Likewise, the earliest record of low back pain is from January 2008. The Board finds that the post-service medical records provide highly probative evidence against this claim. See Owens, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have a continued problem with a back disability in and since service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(b). Turning to the question of a nexus to either service, to his service-connected hip disability, and/or an undiagnosed illness, the Veteran was afforded a VA examination in February 2012. At that time, a diagnosis of low back strain was given. The Veteran gave the examiner a history of his pain and described is present symptoms. The examiner noted treatment records attributing his back pain to very poor posture. After a complete physical examination, the examiner opined that the Veteran's recurring low back strain was likely caused by his posture rather than any undiagnosed condition or an unexplained multisymptom illness. In November 2019, the Veteran was afforded a new VA examination. The examiner noted the Veteran's complete medical and occupational history. Particularly, the examiner noted the Veteran's report that his low back pain started during active service, and that it was aggravated by using body armor and also his hip condition. A diagnosis of lumbosacral strain was given. Imaging was conducted, and no evidence of arthritis, vertebral fracture, or other significant findings were identified. The examiner then stated that the present strain was less likely than not related to any incident of active service, to include the Veteran's reported onset of pain during service. In support of this, the examiner discussed how present imaging failed to show any of the pathologies identified in 2008. Given the advancement in technology since that time, and the advancement that would be expected of such diseases identified in 2008, it was unlikely that the present strain is related to any incident of active service. The examiner also cited to the complete lack of medical records evidencing any type of back complaints during service, despite complaints of other issues throughout. The examiner also considered whether the Veteran's disability in terms of secondary service connection, finding that the condition was less likely than not caused or aggravated by his service-connected left hip condition. In support of this, the examiner noted that there are no medical records evidencing back pain in service. There are no medical records indicating that the Veteran has an altered gait due to his hip disability causing any type of shift in his gait. Likewise, there is no evidence that the back condition preexisted the hip condition. The Board finds these opinions persuasive. They were rendered by a medical specialist in contemplation of the complete medical record. Further, they cited to the Veteran's medical history, and applied that history to known medical principles. The Board has searched the record but found no medical opinions that would contradict the opinions of the VA examiners in this matter. The Board does acknowledge private treatment records from an Orthopedic and Spine Center of the Rockies but notes that those records merely document ongoing thoracic and lumbar pain without normal CT scans, and generally normal gate and range of motion. There is no etiology opinion or implications contained therein that would contradict the VA examiner's opinions. The Board finds these opinions the most competent and credible medical opinions of record because they are provided after a review of the record on appeal and an examination of the Veteran as well as because they are supported by citation to evidence found in the record and controlling medical literature as well as because they are supported by medical reasoning and, as to all but the elbow, these opinions are not contradicted by any other medical evidence of record. See Owens, supra; Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators..."); Colvin, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's back disability is not due to his military service, caused or aggravated by a service connected disability, or an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illnesses of unknown etiology, or a diagnosable chronic multisymptom illness with a partially explained etiology. See 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303(d); 3.317. The Board does acknowledge the Veteran's own assertions that his pain started during active service, as early as 2005, and continued to the present. While the Veteran is certainly competent to report observable symptoms such as pain, once basic competency is met, the Board must assess the credibility of the evidence. While the Veteran asserts his pain was present as early as 2005, there is no medical evidence in the record to support such an assertion. Indeed, the Veteran did not assert low back pain until nearly two years after he separated from his final period of active duty service, at approximately the time of his first claim for a low back disability. Therefore, the Board finds this evidence of limited probative value, and a continuity of symptoms from the time of active service to the present is not shown. The Board does also recognize the Veteran's own firmly held belief that his low back strain is either caused by service or caused or aggravated by his left hip disability, but similarly finds this of limited probative value. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau, supra; see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise (while the Veteran has completed coursework in psychology, there is no indication in the record that he possesses any special knowledge or training with regard to orthopedic or other medical disciplines), and thus, is not competent to make an etiological conclusion regarding the cause of his low back strain, especially in light of the VA examiners' conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of any low back symptoms in service. See id. In sum, the Board finds that the Veteran's low back disability was not manifested during active service and is not otherwise related to any incident of active service. It has also not been caused or aggravated by his service-connected left hip disability nor is it an undiagnosed illness. As such, the claim is denied. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Special Monthly Compensation The Veteran seeks an initial higher rate of special monthly compensation (SMC), for which he is already in receipt of under 38 U.S.C. § 1114 (k), which compensates for loss of use of a creative organ. The Board finds that SMC to any rate higher than this is not warranted. Special monthly compensation is a statutory award, in addition to awards based on the schedular evaluations provided for service-connected disabilities in the Rating Schedule. As an initial matter, the Veteran is in receipt of SMC (k), which compensates for, among other things, loss of use of a creative organ. 38 U.S.C. § 1114 (k); 38 C.F.R. § 3.350 (a). When addressing whether he is entitled to SMC payable at a higher rate, most of the provisions under 38 U.S.C. § 1114 are not applicable. For example, there is also no indication that the Veteran has anatomical loss or loss of use of both hands; anatomical loss or loss of use of both legs at a level, or with complications, preventing natural knee action with prosthesis in place; anatomical loss or loss of use of one arm at a level, or with complications, preventing natural elbow action with prosthesis in place with anatomical loss or loss of use of one leg at a level, or with complications, preventing natural knee action with prosthesis in place; blindness in both eyes having only light perception; or, blindness in both eyes leaving the veteran so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114 (m); 38 C.F.R. § 3.350 (c). There also is no evidence of anatomical loss or loss of use of both arms at a level or with complications, preventing natural elbow action with prosthesis in place; anatomical loss of both legs so near the hip as to prevent use of a prosthetic appliance; anatomical loss of one arm so near the shoulder as to prevent use of a prosthetic appliance with anatomical loss of one leg so near the hip as to prevent use of a prosthetic appliance; or anatomical loss of both eyes or blindness without light perception in both eyes. Under these provisions, amputation is a prerequisite for the award of SMC, except for loss of use of both arms and blindness without light perception in both eyes. 38 U.S.C. § 1114 (n); 38 C.F.R. § 3.350 (d). Upon review of the evidence of record, he does not meet the criteria for the next higher rating payable for SMC (l) through SMC (n), based on additional independent 50 or 100 percent ratings. 38 U.S.C. § 1114 (p); 38 C.F.R. § 3.350 (f)(3)-(4). Neither is there any entitlement to additional SMC based on need for special aid and attendance for those in receipt of SMC (n) through SMC (o). 38 U.S.C. § 1114 (r); 38 C.F.R. § 3.350 (h). He does not have any evidence of inactive tuberculosis. 38 C.F.R. § 3.350 (g). Finally, while he is service connected for residuals of TBI, there is no evidence that those disabilities have rendered him in need of aid and attendance or would render him in need of hospitalization, nursing home care, or other residential institutional care. 38 U.S.C. § 1114 (t); 38 C.F.R. § 3.350 (j). The Board has also considered whether SMC is warranted based on need for aid and attendance or housebound status but finds that it is not. Special monthly compensation benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling, and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is "permanently housebound" by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350 (i)(1). Housebound benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011). However, a total disability rating based on individual unemployability (TDIU) satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more, for purposes of entitlement to special monthly compensation for a housebound rating. Bradley v. Peake, 22 Vet. App. 280, 293 (2008). In other words, a TDIU rating based on a single disability, but not multiple disabilities, is permitted to satisfy the statutory requirement of a total rating. Bradley, 22 Vet. App. at 293. Nonetheless, the TDIU rating based on a single disability that satisfies the total (100 percent) rating requirement must be separate and distinct from the additional disability or disabilities independently ratable at 60 percent or more for purposes of housebound benefits. Bradley, 22 Vet. App. at 293. In addition, the decision to treat multiple disabilities as one under 38 C.F.R. § 4.16 (a) is specifically limited to TDIU ratings. That is, a TDIU rating based on multiple service-connected disabilities does not satisfy the criteria for one total disability in considering entitlement to housebound benefits under 38 U.S.C. § 1114 (s). Bradley, 22 Vet. App. at 290-91. A "TDIU rating that is based on multiple disabilities cannot satisfy the section 1114(s) requirements of 'a service-connected disability' because that requirement must be met by a single disability." Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). However, VA's duty to maximize benefits requires VA to assess all of a claimant's disabilities, regardless of the order in which they were service-connected, to determine whether any combination of disabilities establishes housebound benefits under 38 U.S.C. § 1114 (s). Buie, 24 Vet. App. at 249-250. A veteran is permanently housebound when he is substantially confined to his house (ward or clinical areas, if institutionalized) or immediate premises as a direct result of his service-connected permanent disability or disabilities, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i)(2). In this matter, while the Veteran is in receipt of TDIU, that grant is based upon the Veteran's disabilities taken together, and not based upon any single disability. There is no evidence to indicate that the Veteran's psychiatric disability, migraine disability, or any other disability alone renders him unemployable. Indeed, despite not being employed for the majority of the period on appeal, the Veteran has maintained a robust academic schedule, completing both a Bachelor's and Master's degree during the appeal period with good results, participates in regular medical treatments through VA (outside of his home), and is actively involved in the rearing of his young son. Thus, there is no indication that any single disability has rendered him unemployable. Further, the Veteran's acquired psychiatric disorder the only disability which, on its own, would allow for a schedular grant of TDIU. Even if his acquired psychiatric disorder alone rendered him unemployable, which it does not, he is not service-connected for any other disability independently rated at 60 percent or more, and therefore, he would not meet the criteria for housebound status for SMC purposes. See Bradley, supra. Neither is there any evidence that the Veteran should be found in need of aid and attendance. Special monthly compensation is payable at the aid and attendance rate specified under SMC(l) if a veteran has anatomical loss or loss of use of both feet, or loss of use of one hand and one foot; if he or she is blind or is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; if the veteran is a patient in a nursing home because of mental or physical incapacity; or if he or she is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). The benefit is also warranted if the evidence establishes a factual need for aid and attendance status under the criteria set forth in 38 C.F.R. § 3.352 (a). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid; inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352 (a). A veteran will be found to be bedridden if the condition actually requires that he remain in bed, but not if he voluntarily stays in bed or if a physician merely recommends bed rest. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions that the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Id. Determinations that the veteran is so helpless, as to need regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Id. Although the Board notes that the Veteran has a combined rating of 90 percent with a grant of TDIU, the evidence does not show, and the Veteran does not allege that he is blind or nearly blind or that he is a patient in a nursing home because of mental or physical incapacity. Likewise, he is not permanently bedridden as recent VA examinations have not found his physical disabilities to significantly interfere with ambulation. In fact, the Veteran regularly is able to attend and participate in medical treatment through VA, travels to meet his son, and has stated that he enjoys living in the mountains. Turning to the question of whether there is a factual need for aid and attendance, the Board observes that the Veteran is not rendered so helpless as to need regular aid and attendance due to his service-connected disabilities. While he does experience hip and cervical spine pain, as well as migraine pain, he has not indicated that he requires the aid of another person to manage the minimum daily activities of living. He has been active in the pursuit of his claims, to include going to and participating in multiple VA examinations without any indication that he requires actual physical aid and attendance to do so. In sum, the Board finds that there is no basis upon which to assign any additional special monthly compensation, beyond SMC(k) already granted based on loss of use of a creative organ. Therefore, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107 ; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. TDIU The Veteran seeks entitlement to a TDIU from December 30, 2010, to April 15, 2014. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation because of a service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. In calculating if the Veteran met the above schedular criteria VA combines the Veteran's service-connected orthopedic disorders. The existence or degree of non-service-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render his incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned where the schedular rating is less than total if a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Further, marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The record shows that from December 30, 2010, to April 15, 2014, the record shows that considering the above grants the Veteran is service-connected for the following disabilities: An acquired psychiatric disorder rated as 30 percent disabling from January 15, 2008, and 70 percent disabling from August 15, 2011; Migraine headaches due to a TBI rated as 50 percent disabling from December 30, 2010; Cervical spine disability rated as 10 percent disabling from August 15, 2011; Left hip strain rated as 10 percent disabling from April 29, 2009; Tinnitus rated as 10 percent disabling from May 18, 2010; TBI cognitive impairment rated as 10 percent disabling from December 30, 2010; and Left hip lost abduction/adduction, right hand skin, bilateral hearing loss, and erectile dysfunction each rated as 0 percent disabling, In summary, the Board finds that this record shows that the Veteran meets the schedular requirements of 38 C.F.R. § 4.16(a)(1)-(4) from December 30, 2010, to April 15, 2014, because he has one disability rated as 40 percent or higher (migraine headaches) and had a combined rating of 70 percent or higher at all times from December 30, 2010, to April 15, 2014. Thus, the question for the Board to consider is when, if ever, his service-connected disabilities render him incapable of substantial gainful employment at any time from December 30, 2010, to April 15, 2014. 38 C.F.R. § 4.16(a). In the August 2014 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability (TDIU Claim Form), he reported, in substance, that he had not worked full-time and became too disabled to work in January 2009 because of his service-connected disabilities As to his work history the Veteran reported that from 2003 to 2009 he worked in security. As to his education, the Veteran reported that he had 3-years of college. As to the Veteran's being able to work performing jobs that require sedentary employment and non-sedentary employment, including his past employment in security as well as other possible employment that could make use of his work experience and 3-years of college from December 30, 2010, to April 15, 2014, the Board finds that the medical records show that the problems caused by his service-connected migraine headaches due to a TBI, TBI cognitive impairment, acquired psychiatric disorder cervical spine disability, left hip disabilities, tinnitus, and bilateral hearing loss adversely impact his ability to work in any field because of the overall impairment they have to his body and mind to include the stamina needed to work a full-day, concentrate on the tasks required by employment, and interact effectively with co-workers and/or customers, and carry out the tasks required by employment. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013) (holding that the determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the regional office). The Board also finds that his service-connected migraine headaches due to a TBI, TBI cognitive impairment, acquired psychiatric disorder cervical spine disability, left hip disabilities, tinnitus, and bilateral hearing loss would make it dangerous for the Veteran and his co-workers for him to work in most non-sedentary employments. Id. Similarly, the Board finds that that the migraine headaches due to a TBI, TBI cognitive impairment, acquired psychiatric disorder cervical spine disability, left hip disabilities, tinnitus, and bilateral hearing loss would make it very difficult to learn the new skills needed to work in most sedentary employments, sit for prolonged periods of time, and interact with his co-workers as well as any customers, and carry out the duties required by such employment for the first time. Id. Given the above, the Board finds that the Veteran's service-connected disabilities prevent him from securing or following a "substantially gainful" occupation from December 30, 2010, to April 15, 2014, given his prior vocational history, work experience, and the impact his service-connected migraine headaches due to a TBI, TBI cognitive impairment, acquired psychiatric disorder cervical spine disability, left hip disabilities, tinnitus, and bilateral hearing loss have on obtaining and maintaining substantially gainful non-sedentary employment and sedentary employment, including in his past employment in security, because of the problems they would cause in any work environment. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's service-connected disabilities render him incapable of substantial gainful employment from December 30, 2010, to April 15, 2014, given his prior vocational history, work experience, his education, and the impact his service-connected disabilities have on employment and the claim for a TDIU is granted from December 30, 2010, to April 15, 2014. NEIL T. WERNER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, 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.