Citation Nr: 21032149 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 15-22 291 DATE: May 26, 2021 ORDER Prior to February 15, 2019, an initial 70 percent rating, but no higher, for residuals of a traumatic brain injury (TBI) is granted, subject to the laws and regulations governing the payment of monetary benefits. As of February 15, 2019, a rating in excess of 10 percent for residuals of a TBI is denied. Prior to March 7, 2015, a rating in excess of 30 percent for chronic tension-type headaches (hereinafter, headaches) is denied. From March 7, 2015, to February 14, 2019, a rating in excess of 50 percent for headaches is denied. As of February 15, 2019, a rating of 50 percent, but no higher, for headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. An initial rating in excess of 10 percent for scar on head, residual of TBI (hereinafter, head scar) is denied. Prior to June 27, 2013, special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s) rate is denied. From June 27, 2013, to March 6, 2015, and as of March 2, 2019, SMC pursuant to 38 U.S.C.§ 1114(s) is granted, subject to the laws and regulations governing the payment of monetary benefits. From May 4, 2012, to June 27, 2013, a total disability rating based on individual unemployability due to service-connected disability (hereinafter, TDIU) is granted, subject to the laws and regulations governing the payment of monetary benefits. As of June 27, 2013, the issue of entitlement to a TDIU is dismissed as moot. Service connection for glaucoma is denied. FINDINGS OF FACT 1. Prior to February 15, 2019, the Veteran's TBI residuals were consistent with moderate impairment of memory, attention, concentration, or executive functions and no more than level "3" impairment in any facet of cognitive impairment. 2. From February 15, 2019 onward, the Veteran's TBI residuals were consistent with complaint of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing; three or more subjective symptoms that mildly interfere with work, instrumental activities of daily living or work, family or other close relationships; and no more than level "1" impairment in any facet of cognitive impairment. 3. Prior to March 7, 2015, the Veteran's headaches were consistent with characteristic prostrating attacks occurring on an average of once a month over the last several months; they were not consistent with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 4. As of March 7, 2015, the Veteran's headaches were consistent with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 5. Throughout the pendency of the appeal, the Veteran's head scar is consistent with hypopigmentation, but the area does not exceed six square inches (39 sq. cm.); it is not consistent with gross distortion or assymetry of facial features or visible or palpable tissue loss; the scar is not 5 or more inches (13 or more cm.) in length, or one-quarter inch (0.6 cm.) wide or more at widest part the scar; unstable or painful; inflexible; abnormal in texture; or characteristic of elevation, depression, adherence to underlying tissue, or missing underlying tissue; and there is nothing to support any additional disabling effects caused by the scar. 6. Prior to June 27, 2013, the Veteran did not have a single service-connected disability rated as 100 percent with additional service-connected disabilities independently ratable at 60 percent or more when combined, and he was not permanently housebound, or substantially confined to his house, or immediate premises as a direct result of his service-connected disabilities. 7. As of June 27, 2013, the Veteran is in receipt of a 100 percent rating for service-connected schizophrenia and has additional disability rated at 60 percent or higher. 8. From May 4, 2012, to June 27, 2013, the Veteran was unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities. 9. The Veteran is in receipt of a 100 percent disability rating and SMC from June 27, 2013 onward; a TDIU from June 27, 2013 onward is moot. 10. The Veteran's glaucoma is not causally or etiologically related to military service. CONCLUSIONS OF LAW 1. Prior to February 15, 2019, the criteria for an initial 70 percent rating for residuals of a TBI are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8045. 2. As of February 15, 2019, the criteria for a rating in excess of 10 percent for residuals of a TBI are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8045. 3. The criteria for an initial rating in excess of 30 percent for headaches are not met prior to March 7, 2015. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.20, 4.27, 4.124a, Diagnostic Code 8100. 4. The criteria for a rating in excess of 50 percent for headaches are not met from March 7, 2015, to February 14, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.20, 4.27, 4.124a, Diagnostic Code 8100. 5. As of February 15, 2019, the criteria for a 50 percent rating for headaches are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.20, 4.27, 4.124a, Diagnostic Code 8100. 6. The criteria for an initial disability rating in excess of 10 percent for a head scar are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7800. 7. The criteria for SMC at the housebound rate are not met prior to June 27, 2013. 38 U. S.C. §§ 1114(s), 5107(b); 38 C.F.R. §§ 3.102, 3.350. 8. The criteria for SMC at the housebound rate are met from June 27, 2013, to March 6, 2015. 38 U. S.C. §§ 1114(s), 5107(b); 38 C.F.R. §§ 3.102, 3.350. 9. The criteria for SMC at the housebound rate are met from March 2, 2019, onward. 38 U. S.C. §§ 1114(s), 5107(b); 38 C.F.R. §§ 3.102, 3.350. 10. From May 4, 2012, to June 27, 2013, the criteria for a TDIU are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16(b), 4.19. 11. The appeal concerning entitlement to a TDIU from June 27, 2013, onward is dismissed as moot. 38 U.S.C. § 7105(d)(5); 38 C.F.R. § 4.16. 12. The criteria for service connection for glaucoma are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.303, 3.655. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1966 to March 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from June 2013 and January 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Jurisdiction is currently with the RO in Manchester, New Hampshire. These matters were previously before the Board in October 2018, at which time they were remanded for further development. Increased Ratings Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial rating in excess of 40 percent prior to June 27, 2013, and in excess of 10 percent thereafter for residuals of a TBI. The appeal period before the Board stems from the Veteran's service connection claim for a TBI, which was received on May 4, 2012. When the procedures of 38 C.F.R. § 3.105(e) are applicable, VA must comply with these provisions rather than the notice and duty provisions in the Veterans Claims Assistance Act of 2000. Kitchens v. Brown, 7 Vet. App. 320, 325 (1995); Brown v. Brown, 5 Vet. App. 513 (1993). However, the record reflects that the provisions of 38 C.F.R. § 3.105(e) do not apply because there was not in fact a reduction in the Veteran's rating. See also 38 C.F.R. § 3.951(b). The Veteran was initially granted service connection for a TBI in a June 2013 rating decision and assigned a 40 percent rating. A January 2014 decision increased the rating to 70 percent effective June 27, 2013. During the course of the appeal, in a November 2019 rating decision, the RO granted service connection for schizophrenia with an evaluation of 100 percent and decreased the Veteran's evaluation for a TBI from 70 percent to 10 percent. The RO explained that the disabilities had some similar overlapping symptomatology and that such symptoms could only be used in one evaluation and could not be duplicated as such would be pyramiding under 38 C.F.R. § 4.14. The RO also explained that a majority of the symptoms were attributed to the service-connected schizophrenia. The rating decision indicates the RO determined that the Veteran's symptoms were contemplated by the 100 percent rating for schizophrenia, and assigned a higher rating under those criteria, rather than the lower 70 percent rating for TBI. Such separate evaluations are specifically contemplated by the TBI rating criteria. See 38 C.F.R. § 4.124a, Diagnostic Code 8045. Therefore, the Board finds that the symptoms of the Veteran's TBI were simply recharacterized into multiple diagnostic codes in accordance with the rating criteria and were ultimately increased, not reduced. The regulations governing the reduction of ratings are therefore inapplicable, and the Board will proceed to the merits of the case. The Veteran's TBI residuals are rated under Diagnostic Code 8045. Under 38 C.F.R. § 4.124a, Diagnostic Code 8045, there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive, emotional/behavioral, and physical. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Adjudicators are to evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" (hereafter "the Table"). 38 C.F.R. § 4.124a. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Adjudicators are to evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the Table. However, they are to separately evaluate any residual with a distinct diagnosis that may be evaluated under another Diagnostic Code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the Table. 38 C.F.R. § 4.124a. Adjudicators are 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, they are to evaluate emotional/behavioral symptoms under the criteria in the Table. 38 C.F.R. § 4.124a. Adjudicators are to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate Diagnostic Code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. 38 C.F.R. § 4.124a. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, adjudicators are 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 § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the Table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. 38 C.F.R. § 4.124a. The Table contains 10 important facets of 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 the highest level of impairment labeled "total." However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than total, since any level of impaired consciousness would be totally disabling. Adjudicators are to assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," adjudicators are to assign the overall percentage evaluation 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, the adjudicator should assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. 38 C.F.R. § 4.124a. The evaluation assigned is based upon the highest level of severity for any facet of cognitive impairment and other residuals of TBI not otherwise classified as determined on examination. Only one evaluation is assigned for all the applicable facets. A higher evaluation is not warranted unless a higher level of severity for a facet is established on examination. The Board notes that pursuant to 38 C.F.R. § 4.124a, the Veteran's symptom of headaches associated with his TBI is already rated separately under Diagnostic Code 8100 and, as noted above, his symptoms of schizophrenia are rated under Diagnostic Code 9201. As such, the question turns as to whether any remaining symptoms (not already associated with or rated under another Diagnostic Code) warrant a compensable rating under Diagnostic Code 8045. Regarding the Veteran's schizophrenia evaluation under Diagnostic Code 9201, the Veteran's 100 percent rating considers occupational and social impairment, 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. 38 C.F.R. § 4.130, Diagnostic Code 9201. Regarding the Veteran's separate rating for headaches under Diagnostic Code 8100, the Veteran's 30 percent and 50 percent disability ratings contemplate migraines resulting in characteristic prostrating attacks occurring on an average once a month over the last several months migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The evidence of record includes an August 2012 TBI VA Examination report in which the examiner indicated that there was objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; moderately impaired judgment; mildly decreased motor activity or with moderate slowing due to apraxia; mildly impaired visual spatial orientation; three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships; and one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them. The examiner indicated that the Veteran had no orientation, social interaction, or communication issues and his consciousness was normal. In an October 2013 TBI VA Examination report, an examiner indicated that there was objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; moderately impaired judgment; mildly decreased motor activity or with moderate slowing due to apraxia; mildly impaired visual spatial orientation; three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships; and one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. The examiner indicated that the Veteran had no orientation, social interaction, or communication issues and his consciousness was normal. In a February 2019 TBI VA Examination report, an examiner indicated that there was a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; and three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. The examiner indicated that the Veteran had no judgment, orientation, social interaction, motor activity, visual spatial orientation, neurobehavioral effects, or communication issues and his consciousness was normal. The evidence of record also includes a February 2015 VA examination report. However, the results of the February 2015 VA examination were determined by the examiner to be invalid due to possible poor participant test. Prior to February 15, 2019, a score of 3 is warranted for the facet of memory, attention, concentration, or executive functions based on objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; a score of 2 is warranted for the facet of judgement based on moderately impaired judgment; a score of 2 is warranted for the facet of motor activity based on mildly decreased motor activity or with moderate slowing due to apraxia; a score of 1 is warranted for the facet of visual spatial orientation based on mildly impaired visual spatial orientation; a score of 1 is warranted for the facet of subjective symptoms based on three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships; a score of 2 is warranted for the facet of neurobehavioral prior to October 9, 2013, based on one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them; a score of 1 is warranted for the facet of neurobehavioral from October 9, 2013, to February 15, 2019, based on one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them; a score of 0 is warranted for the facets of social interactions, orientation, communication, and consciousness as there is no evidence of impairment. From February 15, 2019, a score of 1 is warranted for the facet of memory, attention, concentration, or executive functions based on complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; a score of 1 is warranted for the facet of subjective symptoms based on three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships; a 0 score is warranted for the facets of judgment, social interactions, orientation, motor activity, visual spatial orientation, neurobehavioral, communication, and consciousness as there is no evidence of impairment. Restating the above, if no facet is evaluated as "total," adjudicators are to assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. Based on the foregoing, the Board finds that the Veteran's TBI residuals were consistent with a 70 percent rating under Diagnostic Code 8045 prior to February 15, 2019. Specifically, a score of 3 is warranted for the facet of memory based on objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. The Board notes that symptoms related to memory and judgment are expressly contemplated in the schedular criteria of the general rating formula for mental disorders. However, the Board also notes that the November 2019 rating decision reflects that the RO considered several symptoms when evaluating the Veteran's schizophrenia, but did not note impairment of memory, attention, concentration, or executive functions as a symptom encompassed in the evaluation. The Board therefore finds that the Veteran's 70 percent rating is not duplicative or overlapping with the symptoms considered for his separately service-connected schizophrenia. From February 15, 2019, the Veteran's TBI residuals were consistent with a 10 percent rating under Diagnostic Code 8045. Specifically, a score of 1 is warranted for complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; and three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. Ratings higher than 70 percent and 10 percent are not warranted as the Veteran's TBI residuals did not manifest with separate and distinct symptoms which manifest in any facet with a score greater than 3 prior to February 15, 2019 or greater than 1 from February 15, 2019 onward. Based on these findings, a 70 percent rating is warranted prior to February 15, 2019 and a 10 percent rating is warranted from February 15, 2019 onward under Diagnostic Code 8045. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.21, 4.124a, Diagnostic Code 8045. 2. Entitlement to an initial rating in excess of 30 percent prior to March 7, 2015, in excess of 50 percent from March 7, 2015, to February 14, 2019, and in excess of 30 percent as of February 15, 2019 for headaches. The Veteran is currently rated 30 percent for headaches prior to March 7, 2015, 50 percent from March 7, 2015 to February 14, 2019, and 30 percent from February 15, 2019 onward under 38 C.F.R. § 4.124a Diagnostic Code 8100. The appeal period before the Board stems from the receipt of the Veteran's service connection claim on May 4, 2012. Under Diagnostic Code 8100, a 30 percent rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Notably, the rating criteria do not define "prostrating". According to Dorland's Illustrated Medical Dictionary 1554 (31st ed. 2007), "prostration" is defined as "extreme exhaustion or powerlessness." Similarly, the term "productive of severe economic inadaptability" is not defined by VA regulations. However, the United States Court of Appeals for Veterans Claims (Court) has stated that this term is not synonymous with being completely unable to work, and that the phrase "productive of" could be read to mean either "producing" or "capable of producing" economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004). The evidence or record includes an August 2012 VA Headaches Examination report in which an examiner indicated that the Veteran had prostrating attacks of non-migraine headache pain more frequently than once per month and that the Veteran reported light sensitivity, pulsating or throbbing head pain, pain on both sides of the head, and that he took Tylenol for his headaches every day. However, the examiner documented that the Veteran did not have very frequent prostrating and prolonged attacks of non-migraine and/or migraine headache pain. The examiner also indicated that the Veteran reported that headaches impacted his ability to work in that if he were able to work, his headaches are severe enough to cause only occasional absence. In a September 2013 VA Headaches Examination report, an examiner indicated that the Veteran experienced headache pain, pulsating or throbbing head pain, and sensitivity to light. The examiner also indicated that the Veteran occasionally used Tylenol. However, the examiner indicated that the Veteran did not have characteristic prostrating attacks of migraine headache pain, or prostrating attacks of non-migraine headache pain; additionally, the Veteran's headache condition did not impact his ability to work. In a May 7, 2015, private Disability Benefits Questionnaire, Dr. HS indicated that the Veteran reported headaches occurring 3-4 times a week, lasting 1 hour to 2 days depending on the severity, and taking 500 mg of Tylenol twice daily. Dr. HS also indicated that the Veteran reported pulsating or throbbing head pain; pain on both sides of the head; nausea; sensitivity to light; and sensitivity to sound. Dr. HS indicated that the Veteran did not have prostrating attacks of migraine headache pain or frequent prostrating prolonged attacks of migraine headache pain. However, Dr. HS indicated that the Veteran had prostrating and prolonged attacks of non-migraine headache pain more frequently than once per month and very frequent prostrating and prolonged attacks of non-migraine headache pain. Based on this evidence, Dr. HS opined that the Veteran would not be able to hold gainful employment due to his headaches. Dr. HS reasoned that the Veteran would miss work 5-6 days a month due to the headaches, would need to leave early more than 5 times a month, and would also require additional unscheduled breaks. In a February 2019 VA Headaches Examination report, an examiner indicated that the Veteran had characteristic prostrating attacks of migraine/non-migraine headache pain once every month. The examiner also indicated that the Veteran endorsed headaches occurring approximately four times per week, accompanied with sensitivity to light and sound, as well as nausea and vomiting typically relieved by Tylenol. The examiner further indicated that the headache condition impacted the Veteran's ability to work in that when working in the past he typically missed 4-5 days of work per month due to headaches that were severe enough to preclude work. In a February 2019 VA Individual Unemployability Statement, the same examiner indicated that the Veteran would be unable to perform sedentary work when experiencing a headache. Based on the foregoing, the Board finds that prior to March 7, 2015, the Veteran's headaches were consistent with a 30 percent rating and no higher under Diagnostic Code 8100. Prior to March 7, 2015, the Veteran had prostrating attacks of non-migraine headache pain more frequently than once per month; he reported light sensitivity, pulsating or throbbing head pain, and pain on both sides of the head; and taking Tylenol for his headaches. A disability rating higher than 30 percent is not warranted as the August 2012 VA examiner indicated that the Veteran reported that his headaches were severe enough to cause only occasional absence from work and the September 2013 VA examiner indicated that the Veteran's headache condition did not impact his ability to work. As of March 7, 2015, the Veteran's headaches were consistent with a 50 percent rating under Diagnostic Code 8100. The February 2019 VA examiner indicated that the Veteran endorsed headaches occurring approximately four times per week and accompanied with sensitivity to light and sound, as well as nausea and vomiting, and typically relieved by Tylenol. The February 2019 VA examiner also indicated the Veteran would be unable to perform sedentary work when experiencing a headache; the headache condition impacted the Veteran's ability to work in that he typically missed 4-5 days of work per month due to headaches that were severe enough to preclude work. The Board acknowledges that the February 2019 VA examiner indicated that the Veteran did not have prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. However, as stated above, the examiner also indicated that the Veteran would be unable to perform sedentary work when experiencing a headache and the headache condition impacted the Veteran's ability to work in that he typically missed 4-5 days of work per month due to headaches that were severe enough to preclude work. 3. Entitlement to an initial rating in excess of 10 percent for a head scar. The Veteran is currently rated as noncompensable under Diagnostic Code 7800 for scar on head and rated as 10 percent for a right forehead scar under Diagnostic Code 7800. The Veteran cannot be rated twice or more for the same symptomatology as this would overcompensate his service-connected disability for his actual impairment of earning capacity. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The awards of service connection for right forehead scar and scar on head contemplate the same symptomatology. Further, a VA examiner indicated in a January 2019 VA Scars/Disfigurement examination report that the Veteran had service-connected conditions of "scar, right forehead" as well as "scar on head, residual of TBI" and the diagnoses were for the same condition. Therefore, the Board finds that the Veteran is currently rated 10 percent for a head scar associated with his TBI. Diagnostic Codes 7800 to 7805 pertain to scars. 38 C.F.R. § 4.118. The Schedule of ratings for the skin was amended, effective August 13, 2018. See 38 Fed. Reg. 32,592 (July 13, 2018). For the appeal period prior to August 13, 2018, the Board will consider the former version of the diagnostic codes only; however, for the period beginning August 13, 2018, the Board will consider both the old and amended version of the diagnostic codes and rate based on whichever is most favorable to the Veteran. Under both the former and amended criteria for Diagnostic Code 7800, a 10 percent rating is warranted for one characteristic of disfigurement. A 30 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating, the highest rating available under Diagnostic Code 7800, is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Note (1) following Diagnostic Code 7800 identifies 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118: (1) scar 5 or more inches (13 or more cm.) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2) following Diagnostic Code 7800 is not relevant to this appeal. Note (3) following Diagnostic Code 7800 indicates that unretouched color photographs should be considered when evaluating under these criteria. Diagnostic Codes 7801 and 7802 are not for application, as they apply to scars not of the head, face, or neck. Under both the former and amended criteria for Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. Higher ratings of 20 and 30 percent are warranted if there are three or four, or five or more, unstable or painful scars, respectively. If one or more scars are both unstable and painful, a 10 percent rating is added to the rating that is based on the total number of unstable or painful scars. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note 1. Under both the former and amended codes, pursuant to Diagnostic Code 7805, a scar may be rated on any disabling effect(s) not considered as part of Diagnostic Codes 7801 to 7804. The evidence of record includes February 2013, September 2013, and January 2019 VA Scars Disfigurement Examination reports in which the examiners indicated that there was no gross distortion or assymetry of facial features or visible or palpable tissue loss. The examiners also indicated that the scar was not 5 or more inches (13 or more cm.) in length, or one-quarter inch (0.6 cm.) wide or more at its widest part. The examiners further indicated that the scar was not unstable; painful; inflexible; abnormal in texture; or characteristic of elevation, depression, adherence to underlying tissue, or missing underlying tissue. The examiners indicated that there was hypopigmentation but that the area did not exceed six square inches (39 sq. cm.). Based on the foregoing, the Board finds that the Veteran's scar associated with his TBI is consistent with a 10 percent rating and no higher under Diagnostic Code 7800. There was no gross distortion or assymetry of facial features or visible or palpable tissue loss; the scar was not 5 or more inches (13 or more cm.) in length, or one-quarter inch (0.6 cm.) wide or more at widest part the scar; unstable or painful; inflexible; abnormal in texture; or characteristic of elevation, depression, adherence to underlying tissue, or missing underlying tissue; and there is nothing to support any additional disabling effects caused by the Veteran's scar. The preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for the scar at any point during the period on appeal. 4. Entitlement to SMC based on the need for aid and attendance of another person or by reason of being housebound. SMC is a special statutory award in addition to awards based on the schedular evaluations provided in VA's rating schedule and provides a higher rate of compensation for service-connected disabilities. Pertinent to the instant case, SMC is payable where the veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems (statutorily housebound), or (2) is permanently housebound by reason of service-connected disability or disabilities (housebound in fact). This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas 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). Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) 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. In this case, the Board notes that the Veteran is already in receipt of SMC from March 7, 2015, to March 1, 2019 under 38 U.S.C. § 1114, subsection (s) on account of a single service-connected disability rated as 100 percent and additional service-connected disability or disabilities independently ratable at 60 percent or more. A VA SMC examination was scheduled in 2019, but the Veteran failed to report and has not responded or explained in any way the reason for his failure to report to the examination. The Board emphasizes that the duty to assist a claimant is not a one-way street, and in this case the Veteran has failed to cooperate in the development of his claim. Olsen v. Principi, 3 Vet. App. 480 (1992); Wood v. Derwinski, 1 Vet. App. 406 (1991); 38 C.F.R. § 3.655. The evidence does not show that the Veteran's service-connected disabilities result in the Veteran being housebound. An examiner indicated in a December 2014 VA Mental Disorders examination report that the Veteran enjoyed attending church. An examiner indicated in a January 2019 VA Mental Disorders examination report that the Veteran attended treatment group at the Cincinnati VAMC. As the Veteran failed to report for the VA SMC examination and the medical evidence shows that the Veteran leaves his home, the Board finds that the Veteran does not qualify for SMC by reason of being housebound due to his service-connected disabilities. On the other hand, VA has awarded the Veteran a 100 percent rating for service-connected schizophrenia effective June 27, 2013. The Veteran also has additional disability rated at 60 percent or higher (headaches; head scar; residuals, fracture left distal radius; and residuals of TBI) from June 27, 2013, to March 6, 2015, and from March 2, 2019 onward. Thus, entitlement to SMC at the housebound rate (statutorily housebound) under 38 U. S.C. § 1114(s) is granted from June 27, 2013, to March 6, 2015, and from March 2, 2019 onward. An SMC at the housebound rate under 38 U. S.C. § 1114(s) is not warranted prior to June 27, 2013 as the Veteran did not have a single disability rated at 100 percent disabling. 5. Entitlement to a TDIU. As an initial matter, the Board notes that the Veteran is in receipt of a 100 percent disability rating from June 27, 2013 onward. The Court has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate the Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for a TDIU moot where 100 percent schedular rating was awarded for the same period). However, a grant of a 100 percent disability rating does not always render the issue of a TDIU moot. VA's duty to maximize a claimant's benefits includes consideration of whether his disabilities establish entitlement to SMC under 38 U.S.C. § 1114. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In this case, the Veteran is in receipt of both a 100 percent disability rating and SMC from June 27, 2013 onward; therefore, the issue of entitlement to a TDIU from June 27, 2013 onward is moot. Turning to the issue of entitlement to a TDIU prior to June 27, 2013, VA will grant a TDIU when the evidence shows that a Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining whether an appellant is entitled to a total disability rating based upon individual unemployability, neither the appellant's nonservice-connected disabilities nor advancing age may be considered. 38 C.F.R. §§ 3.341(a), 4.19. Factors to be considered are the veteran's education, employment history, and vocational attainment. See Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). The appeal period before the Board stems from the receipt of the Veteran's service connection claims on May 4, 2012. At the outset, the Board notes that the Veteran met the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a) prior to June 27, 2013. Service connection has been established for residuals of TBI (rated as 70 percent disabling); chronic tension-type headaches (rated as 30 percent disabling); right forehead scar (rated as 10 percent disabling); and residuals, fracture left distal radius (rated as 10 percent disabling). The Veteran's combined schedular rating was 70 percent or more with at least one disability ratable at 40 percent or more. After reviewing the evidence of record and resolving all doubt in the Veteran's favor, the Board finds that the Veteran was unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities prior to June 27, 2013. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). See also 38 U.S.C. § 5107. In this regard, the record reflects that the Veteran earned a college diploma and completed some post-graduate course work. Since service, the Veteran reported primary employment working as a data processor. He became too disabled to work in 1975. Turning to the medical evidence of record, in an August 2012 VA TBI Examination report, the examiner indicated that there was objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; moderately impaired judgment; mildly decreased motor activity or moderate slowing due to apraxia; mildly impaired visual spatial orientation; three or more subjective symptoms that mildly interfere with work; and one or more neurobehavioral effects that frequently interfere with workplace interaction. In an August 2012 VA Headaches Examination report, the examiner indicated that the Veteran's headache condition impacts his ability to work in that the Veteran reported that the headaches are severe enough to cause occasional absence. In a December 2012 VA Mental Disorders Examination, the examiner indicated that the occupational and social impairment with regard to his acquired psychiatric disorder was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner also indicated that the Veteran had flattened affect and inability to establish and maintain effective relationships Based on the foregoing, after reviewing the evidence of record and resolving all doubt in the Veteran's favor, the Board finds that the Veteran was unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities prior to June 27, 2013. See Gilbert, 1 Vet. App. 54. See also 38 U.S.C. § 5107. In making this determination, the Board has considered the Veteran's level of education and his primary employment history of working in data processing. As the evidence indicates that the Veteran's service-connected disabilities interfere with his ability to adequately perform in even a sedentary setting, the Board concludes that the record adequately supports the award of a TDIU prior to June 27, 2013 in the Veteran's case. 6. Entitlement to service connection for glaucoma. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). Here, the Veteran was scheduled for a VA examination on October 29, 2019, to determine the nature and etiology of his claimed condition. However, the Veteran did not report for the examination. The file contains an internal VA report for the scheduled VA examination which correctly listed the Veteran's address at the time. There is no evidence of returned mail. While review of the electronic file does not reveal a copy of a letter notifying the Veteran of this scheduled examination, neither the Veteran nor his representative has asserted that the failure to appear was due to a lack of advance notice of the scheduled examination. The Veteran's representative did not raise such a contention in any subsequent correspondence. The Veteran's representative has not indicated that the Veteran failed to receive notice of the examination, provided any explanation for the Veteran's failure to appear, or even requested that the Veteran be scheduled for another examination. Moreover, the Veteran and his representative were informed in a March 2020 supplemental statement of the case that he failed to report for an examination, and he has not indicated a willingness to do so, nor has he claimed that he did not receive notice of the examination, or provided good cause for his failure to report. Accordingly, absent any other evidence to the contrary, the Board finds that the Veteran received sufficient notification in advance of the VA examination scheduled on October 29, 2019. In this regard, the Board is relying upon the presumption of administrative regularity in finding that the Veteran was properly notified of the scheduled VA examination. The Board acknowledges the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) decision in Kyhn v. Shinseki, which struck down the lower Court's reliance on the presumption of regularity in a case in which notification of an upcoming VA examination was not explicitly of record. See Kyhn v. Shinseki, 716 F.3d 572 (Fed. Cir. 2013) (reversing Kyhn v. Shinseki, 23 Vet. App. 335 (2010)). Notably, the appellant in Kyhn expressly argued that he had been unable to attend the scheduled VA examination because proper advance notice had not been provided. The Federal Circuit then ruled that, in such an instance, VA could not rely on evidence outside the record that was before the agency-specifically, the post-hoc affidavits of AOJ employees-in establishing that the agency "had a regular practice of providing [advance] notice of VA examinations." Kyhn, 716 F.3d at 577. In this case, in contrast with the facts in Kyhn, neither the Veteran nor the representative has argued that there was improper notice in advance of the scheduled VA examination. It thus follows that this case more closely resembles the facts in Baxter v. Principi, 17 Vet. App. 407 (2004), wherein an appellant "assiduously avoided" raising the question of whether VA had properly discharged its official notification duties. Baxter, 17 Vet. App. at 410. Consequently, the Court in Baxter held "that the Board need not examine whether the presumption of regularity has been rebutted unless and until an appellant, at a minimum, alleges that he did not receive the document in question." Id. at 411. Significantly, the holding in Baxter was cited approvingly by the Court when it revisited the Kyhn case at the direction of the Federal Circuit. See Kyhn v. Shinseki, 26 Vet. App. 371, 374 (2013) (noting that the "Secretary correctly states that Baxter 'holds that the Board need not examine whether the presumption of regularity has been rebutted unless and until an appellant, at a minimum, alleges that he did not receive the document in question'"). Thus, applying the holding of Baxter to the facts presented in the instant case, the Board finds no need to consider whether the presumption of regularity has been rebutted, namely, because neither the Veteran nor his representative has argued that there was a lack of notice, or insufficient notice, of the VA examination. As such, this claim for service connection for glaucoma must be decided based upon the evidence of record. Turning to the relevant evidence of record, the Veteran's service treatment records (STRs) do not demonstrate complaints of, treatment for, or a diagnosis of glaucoma. Post-service treatment records document a current diagnosis of glaucoma. See August 2014 Alvin C. York. (Continued on the next page) There is no probative evidence linking the Veteran's glaucoma to service. As the record lacks a probative opinion linking the Veteran's glaucoma to service, the preponderance of the evidence is against the claim. To the extent the Veteran himself has provided a nexus opinion, while he has competently reported his symptoms, the matter of whether his glaucoma is related to service is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77, n.4 (Fed. Cir. 2007); 38 C.F.R. § 3.317 (a)(1) and (3). Instead, such a determination must be made by a medical professional with appropriate expertise. Because the Veteran's statements are not based on medical training and/or experience, his assertion that these symptoms relate to service cannot be used to establish the required nexus. In short, the evidence of record does not reflect that the Veteran's glaucoma manifested in service, or for many years thereafter, and there is no probative evidence linking the condition to service. As a result, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim of entitlement to service connection for glaucoma must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, 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.